PRINCIPLES OF MEDICINE: 

COMPRISING 

GENERAL PATHOLOGY AND THERAPEUTICS, 

a 

AND A BRIEF GENERAL VIEW OF 

ETIOLOGY, NOSOLOGY, SEMEIOLOGY, DIAGNOSIS, 
PROGNOSIS AND HYGIENICS. 




CHARLES j: B. WILLIAMS, M.D., F.K.S., 

FELLOW OF THE EOTAL COLLEGE OF PHYSICIANS : 
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE, AND OF CLINICAL MEDICINE, 
AND FIRST PHYSICIAN TO THE HOSPITAL, UNIVERSITY COLLEGE, LONDON }■ 
CONSULTING PHYSICIAN TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST J 
LATE PRESIDENT OF THE PATHOLOGICAL SOCIETY OF LONDON, ETC. 



EDITED, WITH ADDITIONS, 

BY MEREDITH CLYMER, M.D., 

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIA NS J 
LATE PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE, AND OF CLINICAL MEDICINE, IN THE 
FRANKLIN MEDICAL COLLEGE J 
CONSULTING PHYSICIAN TO THE PHILADELPHIA HOSPITAL, ETC. ETC. 



THIRD AMERICAN FROM THE SECOND AND ENLARGED LONDON EDITION. 




* 



LEA 



PHILADELPHIA: 
AND BLANCHARD, 
1848. 



.VVTz.3 



Entered according to the act of Congress, in the year 1848, by 
LEA AND BLANCHARD, 
in the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



LC Control Number 




PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



TO THE 

PATHOLOGICAL SOCIETY OF LONDON, 
&l)i0 boltrme 
IS INSCRIBED, 

BY THEIR 

FAITHFUL AND OBLIGED FRIEND AND LATE PRESIDENT, 

THE AUTHOR. 



PREFACE OF THE AMERICAN EDITOR. 



In the preface of the first American edition, it was remarked that " a 
work on General Pathology, supplies a want in English medical litera- 
ture." The rapid sale of two large editions of the "Principles of Medi- 
cine," and the great favor with which it has been received by the pro- 
fession, confirm this opinion. It possesses the strongest claims to the 
attention of the medical student and practitioner, from the admirable 
manner in which the various inquiries in the different branches of 
pathology are investigated, combined, and generalized by an experi- 
enced practical physician, and directly applied to the investigation and 
treatment of disease. 

The publication of Professor ChomePs classical " Elemens de Patho- 
logic Generate," translated by Drs. F. E. Oliver, and W. W. Morland, 
of Boston, and of Dr. Stille's " General Pathology," since that time, 
— both valuable accessions to our literature — has not superseded the 
necessity of the present work. From their more limited plan, they 
treat chiefly of Etiology, Nosology, Semeiology, Diagnosis and Prognosis ; 
whilst the Nature and Constitution of Disease — the chief subject-matter 
of the following pages — is scarcely touched upon. The scope of a work 
on General Pathology has been thus correctly defined : " The legitimate 
object of a work on General Pathology is the study of diseases in the 
abstract, and in that which they have in common. It should serve as a 
complement to special and descriptive pathology, just as general ana- 
tomy does to descriptive anatomy. It should comprise all that is most 
simple and most elevated in science; on the one hand, the definition of 
the terms, and the description of the phenomena of diseases; on the 
other hand, the discussion of all the fundamental questions, and the ex- 
position of the general principles which should serve to guide the phy- 
sician in the arduous exercise of a profession so intimately connected 
with the dearest interests of humanity. General Pathology, in fact, in- 
cludes within itself the humblest elements, and the most sublime philo- 
sophy of medicine."* 



* Medico-Chirurgical Review, 1843, 



vi 



PREFACE OF THE AMERICAN EDITOR. 



The chief additions by the editor will be found in the sections on Eti- 
ology, Diseases of the Constituents of the Blood, Nutrition, Semeiology, 
Prognosis, and Hygienics. The section on Semeiology has been con- 
siderably enlarged, and an abstract of the general signs of disease 
added. The editor's matter is distinguished thus : [ — C.]. M. C. 

230, Spruce Street, 
Jwne, 1848. 



PREFACE. 



More than a year has elapsed since the first edition of this work was 
out of print, and it has been the subject of continual regret on my part 
that my engagements have so long retarded the completion of the present. 
Some excuse for the delay will, I trust, be found in the very extensive 
additions which it contains, comprising the enunciation and application 
of most of the facts and established deductions made available to the 
science and art of medicine during the last few years. These additions 
pervade almost every portion of the work; but they preponderate in the 
following subjects : — 

In Etiology, mechanical, chemical, and dietetic causes of disease, de- 
fective cleanliness, ventilation, and drainage. In Pathology, the tabular 
views of the elements of disease ; reflex action and sympathy ; elementary 
changes in the blood ; congestion ; determination of blood ; inflammation 
in its nature, manifold results, and modes of treatment ; degeneration of 
textures ; cacoplastic and aplastic deposits, and their treatment, with a 
notice of the action of the cod liver oil; and the whole chapter on Hy- 
gienics, comprisingyboc?, clothing, air, and temperature, exercise, mental 
occupation, sleep, and excretion. 

In endeavoring to adapt the work to the rapid improvements in medi- 
cal science, it is most satisfactory to be able to state that in very few 
instances has it been necessary to retract or supersede the inferences and 
views set forth in the first edition; on many subjects they have been 
confirmed and extended by recent researches to a degree that has not 
less surprised than convinced me of their truth ; as examples, I would 
mention the subjects Congestion, Dropsy, Determination of blood, In- 
flammation, and Deposits. I am quite aware that my views on some of 
these subjects are opposed to those held by several distinguished and 
estimable pathologists ; and the knowledge of this fact has led me to 
test them the more severely by all the experiments which physiology, 
clinical observation, and pathological research could supply; and the 
result of this scrutiny, in which I have been aided by several able fronds? 



vlii 



PREFACE. 



and pupils, has been a firmer and clearer conviction of their substantial 
truth. I would further add in favor of the views put forth on the above 
named subjects, that they, as it were spontaneously, point to remedial 
measures closely corresponding with those which the best experience 
has sanctioned, and they simplify and facilitate the indications of treat- 
ment in a manner that suggests more efficient modes of practice than 
could be obtained by blind experience. 

It is in harmony with the statement just made, that whilst I feel grate- 
ful for the approbation with which this work has been honored by scientific 
men, both in this and in foreign countries, I am especially gratified by 
the favor with which it has been received by practitioners of great ex- 
perience. This favorable reception, as well as the assistance which it 
has afforded me in my systematic course of lectures on practical medi- 
cine, leads me to believe that my attempts to combine science with art 
to place the practice of physic on a more rational basis, have not been 
altogether unsuccessful, and encourages me to hope that the present work 
may further contribute to the same desirable end. 

I am fully aware of the existence of many defects in the accomplishment 
of this work, some of which might be amended by delaying its publica- 
tion a little longer; but the objections to such delay outweigh the pro- 
bable advantages; and I must trust to the leniency of my critics to ex- 
cuse the errors of omission and commission, which it is very difficult to 
exclude in a volume that is at once elementary and yet embraces a most 
extensive range of subjects. 



7, Holies Street, Cavendish Square, 
Feb. 19, 1848. 



PREFACE 

TO THE FIRST EDITION. 



As an apology for the appearance of this publication, it may, I think, 
be stated to be generally acknowledged, that there is at present, no work 
which fully treats of the subject of General Pathology, and its application 
to practical medicine. The present attempt to supply the defect arose 
from my feeling the want of an elementary work on these subjects, by 
aid of which I could introduce to my pupils the science of practical me- 
dicine. With many excellent and elaborate treatises on the details of 
medicine, we have scarcely any which treat of those general principles 
in the nature and treatment of disease, which are really fundamental in 
the practice of medicine. Even the very able work of my distinguished 
friend, Prof. Alison, (to which the following pages owe much,) in the last 
edition, instead of some of these general principles, embraces some of 
these details of Special Pathology. 

It maybe supposed, that in subjects comparatively so modern as those 
embraced in this work, little reference can be made to any but recent 
authors; and for a great portion of the facts and illustrations, I have 
drawn on my own experience in the continual observation of disease, 
during upwards of twenty years, in hospitals and private practice. 
Throughout this experience, I have alw T ays endeavored to keep in mind 
the bearings of physiology and pathology on practical medicine, and to 
render their advances useful, by their application to this art. Many ori- 
ginal facts and opinions have been the result of this mode of study; and 
some of these will be found in the following pages. I cannot expect 
that they will speedily receive a general assent ; but I ask for them the 
test of clinical observation, from which they have been mainly derived. 

It seems quite extraordinary that, notwithstanding the recent rapid 
improvements and comparative perfections of the contributory sciences, 
practical medicine should still halt in the domain of empiricism. A chief 
reason for the anomaly seems to be, that science and practice have been 



X 



PREFACE. 



rarely pursued by the same parties. Scientific men are not and cannot 
be practical, because they have had no experience ; and practitioners 
know little of science, and therefore derive little good from it. Instead 
of working together, these parties are at issue with each other. But it 
is high time to put an end to this feud. Philosophers must descend from 
their transcendental positions, to consider details of practice and purposes 
of utility. Those who would be practitioners must gain from science 
that knowledge and that method which render experience instructive and 
useful. 

In the present effort towards the accomplishment of these objects, I 
am conscious of many deficiencies. Want of time has prevented me 
from treating some subjects as fully as they deserve, particularly those 
of the last chapter. In others, I have studied to be brief, to avoid per- 
plexing the reader with much discussion or detail. For this reason, 
doubtful facts and a variety of conflicting opinions have been withheld ; 
and only the facts best ascertained and the views which seem most tenable 
have been given. By this eclectic method, I have succeeded in reduc- 
ing a very extensive range of subjects within the compass of a moderate 
volume. 

7, Holies Street, Cavendish Square, 
Sept. 22, 1843. 



CONTENTS. 



Preface - - - - - - - - Page v 

PRINCIPLES OF MEDICINE. 

Paragraph. 

Explanation of the Subjects of the Wore: = - p. 17 

1, 2 Principles of medicine. Synonyms. Whence deduced. Division into etiology, 
3, 4 pathogeny, general therapeutics, and other subjects - - p. 17 

Definition of Disease - - - - - p. 17 

5 Standards of comparison. Definition of health. Deviations from health ; in func- 

tion; in structure. 

6 Physiology a standard of healthy function ; anatomy — of structure. 

7 Definition of disease. 

8 Variations in the standard of health. Examples. 

CHAPTER I.— ETIOLOGY— ON THE CAUSES OF DISEASE. 
Section I. — Nature and Division of Causes - - p. 20 — 23 

9 Definition of causes of disease. Antecedent circumstances apt to be mistaken for 

causes. This error to be avoided by proving their occasional absence, and in- 
vestigating the intimate nature of disease. Example. 

10 Causes of disease intrinsic and extrinsic. Examples. 

1 1 Causes of disease not sure in operation ; except those which are very strong. 

12 They generally require predisposition. Examples. 

13 Causes divided into remote and proximate. Remote divided into predisposing and 

exciting. 

14 Co-operation of predisposing and exciting causes generally necessary. Examples. 

Exceptions. 

16 Predisposition generally deficiency of natural power of resistance. Examples of 

the operation of this resisting power. 

18 Predisposition from error of function or structure. Other terms for predisposing 

19 causes; why sometimes inapplicable. Causes are circumstances inducing 
disease. 

Section II. — Predisposing Causes of Disease - - p. 23 — 36 

20 Classification of predisposing causes. 

21,22 I. Debilitating causes and their modes of operation. Imperfect nourishment. Impure 

23 air. Excessive exertion of body or mind. Want of exercise, and sedentary 

24 habits generally. Long continued heat. Long continued cold. Habitual in- 
25 — 28 temperance. Depressing passions. Excessive evacuations. Previous debili- 
29, 30 tating diseases. 

31, 32 II. Excitement, examples. III. Previous disease; operating by change of structure; 
33 by persistence of cause. Examples. 

34, 35 IV. Present disease or defective function. 



xii 



CONTENTS. 



Paragraph. 



36, 37 V. Hereditary constitution. VI. Temperaments. Definition and nature ; sanguine ; 
38- — 41 phlegmatic; bilious; nervous. Diathesis. VII. Age, and its predispositions. 
42 — 46 Infancy. Childhood. Puberty. Full-growth. Adult age. Old age; influ- 
47 — 49 ences exemplified in vascular and nutritive functions. VIII. Sex. IX. Occur 

50 potion. 

Section III. — Exciting Causes of Disease p. 36 — 60 

51 Operation of exciting causes. Division into cognizable and non-cognizable. Clas- 

sification. 

52 I. Cognizable Agents. (1.) Mechanical causes: examples of their physical effects. 

Vital operation of severe injuries. 

53 (2.) Chemical causes: extrinsic; intrinsic ; modes of operation, as local irritants, as 

corrosives, as septics, and as chemical alteratives ; examples of their effects. 
54, 55 (3.) Ingesta. Non- alimentary : examples ; action of salt in excess. Intoxicating 

56 liquors, use and abuse of. Delirium tremens; principles of treatment. Adul- 

57 terations of food, impure water, medicines. Aliment, unfit in quality; a due 

58 mixture requisite. Simple principles, such as fibrin, starch, gum, &c, insuffi- 
cient. Bread the staff of life. Dr. Prout's views on aliments, sanctioned by 

59 familiar experience. Extent of conversion of the elements of food by digestion. 
Dumas's views ; objections. Experiments of Petroz and Boussingault. Liebig's 

60, 61 views. Effects of alimentary principles; albuminous, gelatinous, oleaginous, 
and saccharine, in defect, in excess, or bad in quality. Aliment, generally, in 

62, 63 excess. Defective. Symptoms of inanition. Chossat's experiments on starva- 
tion. 

64 (4.) Violent exertion, effect on the heart, brain, lungs, and other organs. Partial 

65 exertion. Exhaustion from fatigue. Want of exercise. 

66 (5.) Mental emotion. Strong. Slow emotion. Mental anxiety. Excessive men- 

tal exertion. 

67 (6.) Excessive evacuation. Effects. Syncope, cerebral, and cardiac. Other effects 

and resulting diseases. 

68 (7.) Retention, Diminution, and Suppression of Evacuations, alvine, urine, bile, &c. 

69 Lower degrees common in disease. Suppression of artificial discharges ; of 
cutaneous eruptions, &c. 

70 (8.) Defective cleanliness, ventilation, and drainage. Their prevalence; modes in 

71 which they excite disease. Filth, action on skin, &c. Filth in dwellings. De- 

72 fective ventilation often insidious in its operation. Evil results, in dwellings 

73 and public buildings. Defective drainage; results of effluvia from cesspools. 
London sewers. Untrapped drains. Causes and consequences. 

74, 75 (9.) Temperature and Changes. Effects of extreme heat or cold. Extensive burns, 
shock. Cold, applied generally. Experiments of Sir A. Cooper and Chossat. 

76 Stimulating effects of heat. View of Liebig. Partial application of heat. 

77 Sedative effects of cold. Intropulsion of blood. Effect on the arteries. Indi- 

78 rect effects of cold. Chilblains. Warmth to be restored in benumbed parts 

79 gradually. Mode in which cold excites internal disease. Dr. Alison's views: 
objections. It acts by deranging the circulation. Symptoms of "cold caught.'" 

80 Means of diminishing susceptibility to cold. Cold bathing. Water cure. 

81 Effects of cold proportioned to previous state of the body. Atmospheric 
changes. 



Section IV. — Non-cognizabee Agents p. 60 — 67 

Definition and division into Endemic, Epidemic, and Infectious. 

(I.) Endemic causes. Proofs of their existence. Sources. Malaria. Nature of 
malaria. Its properties. Sources of malaria. Its virulence in proportion to 
heat with moisture. Morbid effects of malaria. Periodicity of their attacks, 
cause of this. Kinds of malaria. Endemic disease from cognizable causes. 

(II.) Epidemic causes. Proofs of their existence. Epidemic. Cognizable causes 
distinguished from non-cognizable. Epidemic constitutions or periods. Nature 
of epidemic influences. Dr. Prout's observations. Animalcule origin of epi- 
demic diseases. 

(III.) Infectious causes. Proofs of their existence. Modes of infection: by 
wounds; by contact; by aerial communications; by several modes. Difficul- 
ties of explaining infection. Analogy of fermentation ; of animal and vegetable 
generation ; examples. Parasitic view of infection confirmed by circumstances 



82 

83, 84 

85 

86 

87, 88 
89, 90 
91 

92 

93, 94 
95, 96 
97, 98 
99, 100 



CONTENTS. 



xiii 



Paragraph. 

101 which promote and check it. Peculiarities of infectious diseases, of endemic 

102 — 104 diseases, of epidemic diseases. Diseases propagated in several ways. Pesti- 
105 lences. General operation of all these causes depressing, but may excite reac- 

tion. Effect modified by the weather. 



CHAPTER II.— PATHOLOGY (PROPER)— THE NATURE AND 
CONSTITUTION OF DISEASE. 



106 Disease composed of elements. Analogy with chemistry, &c. Primary ele- 

107 ments of structure and function ; healthy and diseased. Primary elements 

108 of disease. Alterations of these elements in degree, and in kind. Table of 

109 primary elements of disease. Table of proximate elements of disease; in 

110 excess, defect, and perversion. These elements are the especial objects of 
general pathology - - - - - p. 68 — 70 

FUNCTIONAL DISEASES.— PRIMARY ELEMENTS. 
Section I. — Diseased Irritability p. 73 — 76 

111 Irritability. The distinctive property of muscular fibre. In excess. Varieties 
112 — 114 in strength, in mobility, and in duration. Examples, causes. Remedial 
115 measures. 

116 — 118 Defective, in force, in mobility. Connection of irritability with nerves not essen- 

119 tial. Remedial measures. 

Section II. — Diseased Tonicity - - - p. 70 — 73 

120 Tonicity; distinct from irritability; proved by different effects of heat and cold. 

Long known empirically. 
121, 122 Excessive. Examples : effect on pulse. Remedial measures. 
123,124 Defective. Examples: retarded and dichrotous pulse. Remedial measures. 

Section III. — DiseasedSensibility - - - p. 76 — 82 

125 Sensibility referable to the nervous system, and divided into general and local. 

126 General. Excessive, from excitement, from disease, from temperament. Patho- 
127,128 logical causes. Remedial measures. Inhalation of ether; mode of action. 

Inhalation of chloroform, see Appendix. 
129,130 Defective. Causes ; from disease, age, temperament. Remedies. 

131 Perverted. Examples; causes. Remedies. 

132 Local sensibility. Variations illustrated by experiment. Pathological causes. 
133 — 136 Excessive, in orifices, in internal organs. Pain, and other varieties. Remedial 
137, 138 measures. Defective. Paralysis of sensation. Remedies. 

Section IV. — Diseased Voluntary Motion - p. 82> — 85 

139 Division into general and partial. 

140, 141 General voluntary motion, in Excess: examples. Defective: examples. Per- 
142 verted: examples. 

143, 144 Partial, excessive, rare. Defective; pathological causes: examples. Remedies 
145 — 147 for diseased voluntary motion ; excessive. Defective local. Perverted. 

Section V. — Diseases of Reflex and Sympathetic Nervous In- 
fluence - - - - - p. 82 — 91 

148,149 Natural reflex function: examples. Excessive, in involuntary muscles; ex- 
150,151 amples. In voluntary muscles : examples. Convulsions ; centric and eccen- 

152 trie. Partial, by reflected irritation. Irritation of involuntary muscles; the 

153 spinal marrow the centre of reflexion. Pathological causes of inordinate 
excitomotion ; irritation of spinal marrow or its nerves; accumulation by 
rest; from action of opium, &c. 

154 Defective reflex motion. In coma, asphyxia, sinking, &c. Remedial measures for 

155 excessive. Narcotics, sedatives, stimulants, tonics. For defective. Stimu- 
lants; opium. 

156, 157 Reflected or sympathetic sensations. Examples. Remedies. 



XIV CONTENTS. 



Paragraph. 



Section VI. — Diseases of Secretion - - - p. 91 — { 



158 Secretion due to a vital property, aided by chemical affinity; not to be ascribed 
to nervous influence. 

159, 160 Changes due to altered supply of blood, or to nervous influence. Excessive. 

161 — 164 Effects; forwards; examples; backwards. On the organ: examples. On the 

165,166 blood: examples. Remedies. Depletion. Astringents. Alteratives. 

167 — 169 Defective secretion. Causes. Effects: forwards; examples; backwards; on the 

170,171 organ; examples. Suppression of excretions; extreme, moderate; in idiopathic 

172, 173 and symptomatic fevers, and other diseases. Remedies, through the circula- 

174, 175 tion. Special stimulants. Alteratives. Tonics. Substitutes for defective 

176 — 178 secretion. Perverted secretion. Examples. Effects. Remedies. 

Section VII. — Diseases of the Constituents of the Blood p. 99 

179 Constituents of the blood, when altered, form elements of disease. 

180, 181 Enumeration of constituents and modes of alteration. Chemical composition of 
the blood. 

Diseases of bed Particles p. 99 — 106 

182 — 184 Natural offices and proportions. Excess. Examples. Signs and effects. 
185, 186 Defective. Examples, and effects. Alterations; in color; in shape and size; 
187,188 breaking up. Arterial change ; cause. Mulder's notion. Mr. W. Jones' ob- 
189,190 servations ; explanation. Mr. Gulliver's observations. Origin of red particles. 
191 — 193 Causes of their decrease. Disorders of spleen and uterus. Remedies for ex- 
cess, defect, and alteration. 

Section VIII. — Fibrin and White Corpuscles p. 106 — 116 

194 Nature of fibrin. Purposes. Structure, in washed clot, or lymph; composition. 

195 Excess. Examples ; signs and effects. Increase of white globules. Buffy 
196,197 coat present without excess of fibrin. Defect. Examples; fluidity of blood. 
198 Causes. Effects ; hemorrhage, congestion, venous murmurs, &c. 

199 — 201 Alterations in quality ; apparent from character of coagulum, which shows pro- 

202 perties of self-coagulation, contraction, and separation. Self-coagulation; varie* 

203,204 ties and causes. Contraction; varieties and causes. Separation; causes, 

205, 206 varieties. Causes of the buffy coat. Appearances of coagulated blood. 

207, 208 Large clot; small clot. Separated and cupped; mode of exhibiting these pro- 

209, 210 perties. Source of fibrin, and formation of white globules. Increase by in- 

211, 212 fiammation. Material of coagulable lymph. Varieties. Coagulation of fibrin 

213 during life. Vegetation and polypi. 

214,215 Remedies for excess of Fibrin. Blood-letting. Evacuants. Mr. Blake's experiments. 

216 Diet. Remedies for defect; diet; regimen; stimulants; tonics; antiseptics. 

217 — 219 Means of altering quality of fibrin; depletion; alteratives. Tonics; diet. 

Section IX. — Albumen and other Animal Principles Dissolved in 

the Serum - - - - - - p. 116, 117 

220 Natural offices of albumen. 

221,222 Excess. Examples. Causes. Remedies. Defect. Examples. Effects. Remedies. 

Section X. — Oil ....... p. H8 

223, 224 Excess. Examples. Milky serum. Depends on the presence of unassimilated 
chyle. Cholesterine. Causes, Sources of fat. Causes of obesity. Remedies. 
Defect. Cause of atrophy. 

Section XL— Saline Matter .... p. 119, 120 

225 — 227 Excess. Thirst caused by salt. Defect: in yellow fever and malignant cholera. 

Effect of saline injections. Use of salines in fevers. Defect of potash the 
cause of scurvy; See Appendix. 

Section XIL— Water - - - - - p. 120, 121 

228 — 230 Excess. Examples and effects. From too much drink. Defect. Examples. 
231 Symptoms. Causes. Effects of cholera — of abstinence from liquids. Re- 

medies for excess and defect. Water cure and dry diet. 



CONTENTS. 



XV 



Paragraph, 



Section XIIT. — Changes in the blood by respiration - p. 121 — 126 

232 — 234 Analysis of the changes. Excess. Examples in disease? Defect: the element 

235,236 of asphyxia. Effect proportioned to suddenness as well as degree. Explana- 

237 tion of this. Analysis of asphyxia. Classification of symptoms. Defect 

238 gradually induced. Hybernation. Cyanosis: state of the functions; little 

239 muscle and much fat ; with defective respiration. Emphysema. Remedies 

240 for defect; Lowering functional activity. Treatment of asphyxia. Stimu- 
241,242 lants. Warm bath. Promoting respiration. Other means of arterializing the 
243 blood. Treatment of congestion of apncea. Diet in dyspnoea. Excess of 
244 — 246 changes by respiration: in rheumatism? Respiration of oxygen gas. Effects 

explained. Carbonic acid may asphyxiate independently of the exclusion of 

247 oxygen. Liebig's theory of the action of hydrocyanic acid controverted. 

Section XIV. — Changes in the Blood by Excretion - p. 127 — 129 

248 Defective secretion of urine. Experiments of Prevost and Dumas, of Bernard 

249 and Barreswil. Effects of diseased kidneys. Acute and chronic albuminuria. 

250 Defective secretion of bile. Examples. Effects. Of perspiratory secretion ; 

251 checked by cold. Vicarious action of skin and kidneys. Rheumatism; 

252 materies morbi. Remedies to be directed to this element. 



Section XV. — Changes in the Blood from the Transformation of 

Chyle and of the Textures - - p. 129 — 134 

Natural changes uncertain. Lithic acid diseases. Diet, &c. producing them. 
Operation of colchicum. Effects on the kidneys. Nephralgia, &c. Gout ; 
varieties, effects. 

Formation of sugar in diabetes. Effects and treatment in gout and rheumatism 
contrasted. Production of urea in excess. Remedies. Obesity. Fatty degenera- 
tion. 

Section XVI. — Changed Properties of the Blood from the pre- 
sence of foreign matters - p. 134 — 136 

259 The blood the seat of morbid poisons; proofs; and of germs of malignant disease. 

260 Treatment of morbific matters in the blood. 



253 
254 

255 

256—258 



CHAPTER III.— PROXIMATE ELEMENTS OF DISEASE. 

Section I. — Anjemia - - - - p. 1 37 — 145 

261 Explanation of proximate elements of disease. 

262 — 264 General anaemia. Nature, exciting causes, and symptoms. Physical signs. 

265 — 267 Changes in the blood. Symptoms of excitement in anaemia. Explanation of 

268,269 these symptoms. Symptoms of coma, &c. Cases and interpretation of natuie 

270,271 of anaemic coma. Nutrition in anaemia. Fatal terminations. Remedial mea- 

272 sures. Regimen and diet. Medicines. Venous murmurs. 

273 Partial ancemia. Examples. Effects. 

Section H. — Hyperemia or Excess of Blood. - - p. 145 

274 Definition and nature. Classification of varieties. 



Section III. — Plethora — General Excess of Blood - p. 146 — 150 

275 — 277 Origin of plethora. Subjects. Symptoms. Tendencies. Causes. Division 
278, 279 into Sthenic and Asthenic. Symptoms of Sthenic. Subjects. Tendencies. 
281 — 283 Asthenic. Symptoms. Subjects. Tendencies. Results. Fever. Gout. 
284 — 286 Remedial measures. Blood-letting: where unfit. In sthenic, other measures 
needed. In asthenic, tonics as well as evacuants. 



XVI 



CONTENTS. 



Paragraph. 

Local Hyperemia. Excess of Blood in a part. 
Section IV. — With Motion Diminished - - p. 15G — 165 



287,288 Congestion analyzed. Its causes classed. 

289 Congestion from venous obstruction. Examples, in health and in disease. Ex- 

planation of congestion in emphysema. 

290 Congestion from atony of the vessels. From general debility. Hypostatic. From 
291,292 over-distention. Examples. From intropulsive action of cold and malaria. 
293, 294 Over excitement or inflammation. Examples and illustrations by microscope. 
295,296 Stagnation in the vessels. From arrest of secretion or capillary circulation. 

298 From imperfect respiration. (Power of the heart sufficient of itself to main- 
tain the circulation. Dr. Sharpey's experiment. Microscopic examinations; 
fallacies. Objections to the supposition of spontaneous movement of the 
blood particles.) Observations of Mr. Erichsen. Obstruction to circulation in 

299 asphyxia is from contraction of the small arteries. Atony of vessels impedes 
300 — 302 transit of blood. Experiments to show the neutralization of force in the flaccid 

vessels. Cause of long continuance of congestion. 
303 Symptoms and effects of congestion. Effects on secretion explained. Production . 

305, 306 of flux. Examples. Considerable congestion required to produce dropsy. 

307 Amount of tension and quality of blood determine quality of effusion, liquid 

308 and solid. Examples. Albuminuria referred to congestion of the kidney. 
309, 310 Reasons. Congestion continuing causes hypertrophy of a peculiar kmd. 
31 1, 312 Origin of granular disease and cirrhosis. Other instances. Effects of local con- 
gestion on the system. 

313 Remedies for congestion. Removal of causes, venous obstruction and causes of 

314,315 atony. Posture. Pressure. Friction. Exercise. Astringents and tonics; 
316, 317 when inapplicable. Stimulant remedies; Operation shown by the microscope; 
318 when hurtful. Depletion and other cvacuants. Heemostasis or counter con- 

319,320 gestion. Preceding remedies combined or alternated. Prevention of conges- 
tions by increasing tone. 

Section V. — Local Hyperemia. Excess of Blood in a Part, with 

Motion increased. Determination of Blood - p. 165 — 175 

321,322 Examples in health and in disease. Determination to the head. Examples with 

324,325 symptoms. Caused by stimuli. Physical cause of determination of blood. 

326, 327 Enlargement of arteries proved, by experiment and microscope. Dr. Billing's 

328,329 view. Cause of the enlargement, a loss of tonicity. Final cause of determina- 

330 tion to supply more blood where wanted. Determination from intropulsion. 

331 Subjects of determination. Determination may cause anaemia in other parts. 

332 Determination affects large arteries. 

333, 334 Symptoms and effects of determination of blood. Parts most subject to it. To the 

335, 336 head. Explanation of its different effects in different cases. To the kidneys. 

337 — 340 To the mucous membranes. To the skin. Other symptoms. Determination 

341 if continued leads to hypertrophy. 

342, 343 Remedies. Removal of causes. Means which promote the tonic contraction of 

344 — 346 dilated arteries. Cold. Astringents. Derivants. Posture. Evacuants. 

Blood-letting; general and local; its effect seen by the microscope. Cases 

347, 348 requiring blood letting. Remedies to relax the arterial system and quiet the 

349 heart. Measures to equalize and strengthen the circulation. Tonics. 

Section VI. — Results of Hyperemia - - - p. 175 — 195 

350 Hemorrhage, flux, and dropsy, results short of inflammation. 

351 Hemorrhage from plethora. Examples. Epistaxis, hematemesis, Sec, from con- 

352 gestion of venous obstruction. Examples. Pulmonary, bronchial, gastric, &c. 

353 From atony of vessels; from posture; from intropulsion of cold. Examples. 
354,355 From determination of blood. Examples. Epistaxis ; apoplexy ; hematemesis. 
356 Additional element of hemorrhage in the vessels or in the blood. Blood- 
357, 358 vessels diseased. Examples. Blood diseased. Hemorrhagic diathesis. Mode 
359 in which blood is effused. By rupture or through pores? 

360,361 Varieties of hemorrhage. Sthenic and asthenic defined. Symptoms. Molimen 

362 hemorrhagicum : jerking pulse, how produced. Faintness; Reaction. Transi- 

363,364 tion to inflammation. Examples. Local effects and symptoms. Passive 

365 hemorrhage. 



CONTENTS. 



xvii 



Paragraph. 

366, 367 Treatment of hemorrhage. Remedies for hyperemia. Styptics. Cases re- 
368 s 369 quiring a speedy check. Active or sthenic. Passive or asthenic. Mecha- 
370 nical means. Special styptics. Internal remedies. Tonics, purgatives, and 

styptics. 

Flux and Dropsy. From plethora. Examples. From congestion. Experi- 
ment of Lower. Examples in disease. 
From weakness of the vessels. After excitement. Intropulsion of cold. 
From determination of blood. Examples; active flux; active dropsy. 
Flux and dropsy vicarious. Examples. Circumstances causing hyperemia to 
end in these results : in the vessels : in the blood. Combination of these cir- 
cumstances in anaemia. Diseased blood from defective excretion, especially 
by the kidneys. Examples and proofs. Cause of anasarca after scarlatina. 
Dropsy and flux with albuminuria: why inflammatory: resemblance to 
rheumatism. Thinness of blood cause of asthenic dropsy. Dropsy from 
retention of water and excrementitious matter in the blood. Malnutrition. 
Proofs. Distinctive pathology of fluxes and dropsy. Causes of each. 
General treatment of flux and dropsy. Remedies for hyperaemia. Remedies for 

malexcretion and malnutrition. 
Treatment of fluxes. Removal of causes. Derivants. For sthenic flux ; evacu- 
ants and depletion ; not to be hastily checked. For asthenic flux ; astringents 
and tonics. Dry and tonic regimen. 
Treatment of dropsy. Means to remove effusion and restore action of kidneys in 
sthenic dropsy. Means to improve the blood in asthenia. Recurrence of 
dropsy requires variation of remedies. Circumstances which indicate tap- 
ping or puncture. Cautions. 



Section VII. — Local Hyperemia, Excess of Blood in a part, with Mo- 
tion PARTLY INCREASED, PARTLY DIMINISHED INFLAMMATION 

p. 195—271 

399,400 Inflammation not understood from its elements not being studied. Definition 
from nature ; from signs. 

401 Causes of Inflammation and their Mode of Operation. Predisposing 

weakness or excitement. Exciting causes divided into local and general ; 

402 direct and indirect. Local irritants ; mechanical, chemical, and vital. Exam- 
403, 404 pies. Indirect causes produce congestion. Causes mixed in operation. 
405, 406 Checked hemorrhage and flux. Irritants operate primarily on the nerves. 

407 But inflammation is sometimes excited without nervous irritation. Cause 

408 essentially acts on vessels, producing sometimes determination first, some- 
times congestion. 

409 Phenomena and nature of inflammation. Difference from congestion; 
410,411 from determination. Essential characters established: increase of blood, 

with motion increased and diminished. Cause of the obstruction. Views 
412, 413 of Cullen, W. Phillip, Hunter, Kaltenbrunner, and Alison, considered. Atony 

414 of the vessels a partial cause of obstruction. Examples and experiments. 

415 Another cause within the vessels: adhesion of white globules; their increase. 

416 Description and production of white globules; Mr. Addison's observations; 

417 Mr. Gulliver's. Appearance of frog's web after irritation. Adhesive pro- 
perty of white globules; those recently formed have no cell-wall. Share 
which the red corpuscles take in the obstruction. The presence and proper- 

418 ties of white globules essential to inflammation. Conclusions as to the 
419, 420 obstruction of inflammation. Effect of obstruction to expend force on the 

421 arterial capillaries. This opposition of obstruction to force also the cause of 
destruction. 

422 Effects of inflammation on vital properties ; on secretions. 

423, 424 Effusions; general character; microscopic character. Exudation corpuscles. 

Elementary solids of inflammatory effusions. Molecules. Granules. Fibrils. 
425, 426 Exudation corpuscles. Pus globules. Tubercle. Mode of formation of 

some of these. Variety in their plasticity and organizability. Other effects 

427 of inflammation. Softening. Suppuration. Slough. Gangrene. Induration. 

428 Symptoms and effects of inflammation. Divided into local and general. 
429,430 Local symptoms. Redness; causes; varieties; changes. Heat; cause; indica~ 
431,432 tions. Swelling; causes; varieties from texture. Pain; causes. Degrees 



1* 



373—375 

376—378 
379 

380—382 

383 

384 

385 
386 
387 

388, 389 

390 

391 

392, 393 
394 

395 

396, 397 
398 



xviii 



CONTENTS. 



Paragraph. 



433, 434 and varieties and their causes. Other sensations. Effect of inflammation on 
435, 436 contractility. On other functions and symptoms. 

437 Constitutional symptoms. Inflammatory fever. Change in the blood. Cause 

438, 439 of the increase of the fibrin and its contractile property. This not the sole 
cause of inflammatory fever. Pathology of inflammatory fever. Causes. 
440, 441 Reaction, irritation, altered condition of the blood. Why some functions are 

442 excited and others impaired. Symptoms of inflammatory fever. Its varie- 

443 ties : high, low. Type of fever from cause or seat of inflammation. Ex- 

444 planation of this. Remittent and intermittent fever. Apyrexia. Injury to 
blood in continued inflammation. 

Nature and Symptoms of the Results on Terminations of Inflammation. 

445, 446 Division. The results seldom occur singly. Resolution. Its nature. Modes 
447, 448 of occurrence. Local symptoms. Constitutional symptoms of resolution. 

Critical discharges. Lateritious sediments; cause; nature; reason of ab- 
sence; &c. 

449 Effusion (including adhesion). Not always a termination. History of effusions 

450 in serous membranes. Coagulable lymph. Varieties. Euplastic. Mode of 

451 organization. Formation of vessels. Views of Kiernan, Travers, Vogel, 
452, 453 Liston. Cacoplastic lymph. Varieties and effects. Aplastic lymph. Causes 
454, 455 of these low products. Effusions of mucous membranes. Interstitial deposit. 
456, 457 Changes of mucus. Effusion in skin: varieties of cutaneous inflammation. 
458,459 Effusion in cellular texture. In parenchymata. Symptoms of effusion. 

460 Suppuration and ulceration. Nature of pus. Microscopical characters. Distinc- 

tion between exudation corpuscles and pus. Alteration by acetic acid ; by 

461 distilled water. Its want of cohesion. Explanation of this. Liquefaction of 

462 tissues in suppuration. Chemical changes. Causes of suppuration. Cir- 
cumstances tending to the conversion of the deutoxide of protein into the 
tritoxide. 1. Intensity and continuance of inflammation. 2. Access of air. 
3. Suppurative diathesis Examples. Mode in which they act. Pus in the 

463 blood. Process of suppuration explained: death of tissues by pressure; 
liquefaction and absorption of all but pus globules. Varieties of suppuration. 

464 Diffused. Abscess: pyogenic membrane: pointing. Opening and healing 
465, 466 of abscesses. Granulations. Ulceration. Varieties. Causes. Softening of 
467 textures. Suppuration a work of destruction, therefore depressing. Symp- 
468,469 toms of suppuration. Local: constitutional: varieties caused by limitation, 

470 or not, of suppuration. Purulent deposits. Nature and causes. No true 
absorption of pus. Pus frequently in the blood in severe inflammation. 

471 Cachaamia usually precedes pyaemia. Depression from suppuration. Cause 
of rigors. Hectic fever. Varieties of pus ; laudable; ill conditioned. 

473,474 Gangrene. Process of sloughing; gangrene; and sphacelus. Causes of gan- 

475 grene; interrupted circulation; noxious agents. Local symptoms and effects 

476 of gangrene. Varieties. Constitutional symptoms. Combinations and grada- 
tions of the results of inflammation. 

Varieties of Inflammation. 

477,478 Sthenic and asthenic; symptoms and results. Acute inflammation generally 

479 sthenic; symptoms, duration, products. Subacute. Chronic; generally asthenic ; 
symptoms, duration, results. Cause of their variety. 

480 Congestive inflammation; nature, symptoms, results. 

481 Phlegmonous inflammation; nature; causes; type and symptoms. 

482 Erythematic and erysipelatous; local symptoms and effects; fever; cause spe- 

483 cific. Pyaemia. Pellicular; asthenic; symptoms; low fever. Plastic inflam- 
mation of mucous membranes. Aphthae of adults often attended by the 

484 growth of a confervoid vegetable. Aphthae of children. Hemorrhagic 
inflammation; causes. 

485 Scrofulous inflammation ; asthenic; peculiar symptoms. Microscopic characters 

of scrofulous matter. Changes which it undergoes. Scrofulous diathesis ; its 
external marks ; symptoms and causes. Course and results of inflammation 
486, 487 in scrofulous subjects. Condition of the blood. Gouty and rheumatic inflam- 
mations. Nature and causes. Gonorrheal inflammation; seat and effects. 
Syphilitic inflammation ; seat and effects. 



CONTENTS. 



xix 



Paragraph. 



4S8 Treatment of inflammation", best understood from knowledge of its elements 

489 and of counteracting measures. Tabular view of constituents of inflam- 
mation. 

490 Tabular view of the chief elements of inflammatory disease, and their reme- 

491 dies. Comments on these principles of treatment. Remedies for incipient 

492 inflammation; 1, for congestion; 2 and 3, for irritation of nerves and vessels 

493 for established local inflammation; 4, for determination to the part; 5 and 6, 

494 for obstruction in the part from atonic enlargement of the capillaries, and by 
adhesion of the white particles with accumulation and impaction of the red 

495 ones ; 7, Distension of vessels ; 8, for effusions from the vessels ; 9, for increased 
496, 497 absorption; 10, for impeded circulation in the part; 11, for increased circulation 
498, 499 around the obstructed part. 

500 Treatment of inflammation with fever. Local remedies secondary. Chief reme- 

501 dies, general blood-letting; effect. Tolerance of blood-letting ; cause. Objects 
502, 503 and mode of blood4etting ; in recent inflammation; in confirmed inflamma- 
tion; in inflammation with plethora; in anaemic subjects; substitutes. Local 

504 blood4etting; uses. Evacuants; purgatives; combinations. Tartarized anti- 

505,506 mony; modes of administration ; modes of operation. Mercury. Calomel 
507 and opium; modes of exhibition ; modes of operation. Refrigerants. Sa- 

508, 509 lines. Sedatives. Diuretics. Counter-irritation. Antiphlogistic regimen and 
510,511 diet. 16. Exhaustion. 17. Depression from poison. Remedies: their mode 
512 of action. Stimulants, antiseptics, tonics, &c. 18. Treatment for products of 

inflammation, liquid and solid. 

Treatment of Varieties of Inflammation. 

513 — 516 Sthenic. Asthenic. Acute. Subacute. Chronic. Congestive. Phlegmonous. 
517 — 519 Erysipelatous. Pellicular. Hemorrhagic. Scrofulous. Treatment of the 
520, 521 scrofulous diathesis and deposits. Cod liver oil. Rheumatic and gouty. 
Gonorrhoeal and syphilitic. 



CHAPTER IV. — STRUCTURAL DISEASES ; OR DISEASES OF NUTRITION. 

Section L — Nature and Classification - - - p. 272 — 275 



522 Arrangement of structural diseases. Table of elements. Structural disease 

523 often complicated. Modifications of natural nutrition. Material of nutrition 

524 of fibrin. Modes and process of nutrition. Variations in nutrition ; causes. 
Relation to nervous influence. 

Section II. — Increased Nutrition — Hypertrophy - p. 275 — 277 

525 — 527 Varieties. Simple hypertrophy ; of muscles. Examples of interstitial textures. 

528 Of epidermis; varieties in skin diseases. Complex hypertrophy; uterus; 

529 breasts ; brain ; follicles ; bursa?, &c. Liver and spleen. Treatment of 
hypertrophy. 

Section III. — Diminished Nutrition — Atrophy - - p. 278 — 282 

530 General emaciation. Causes: divided into those which promote decay and 

those which prevent nutrition. Cause of emaciation in fevers. Views of 

531 Dr. Hodgkin; Rokitansky. Drains from the body. Causes which prevent 

532 reparatory nutrition. When traced to its cause, general atrophy an important 

533 sign. Partial atrophy from defective supply of blood. Examples. Treat- 

534 ment of atrophy, partial and general. 

Perverted Nutrition. 

535 Alterations in kind; in texture. 



Section IV. — Induration and Softening - - p. 282 — 285 

536, 537 Both may be independent of inflammation. Nature of induration. Often ac- 
companied by transformation of tissues or interstitial deposit. Examples. 



XX 



CONTENTS. 



Paragraph. 

538 Softening. Specific causes. Common causes. Partial softening ; nature. Ex- 

539 amples. Treatment of induration and softening, opposite but parallel. Treat- 
540, 541 ment of softening generally tonic and supporting. Action of nitric acid, &c. 

Specific causes. 

Section V. — Transformation of Textures - - 285 — 293 

542 Transformations generally degenerations. Exceptions: skin and mucous mem- 

543 brane. Transformation of muscle. Four kinds of progressive degeneration : 
Fibrous, granular, fatty, and osseous or calcareous. Fibrous, resembles fibrous 
tissue, but apt to degenerate further. Muscles and parenchymatous organs 

544 exhibit this change, sometimes owing to interstitial deposit. Granular, a ca- 
coplastic interstitial deposit or transformation; invades morbid as well as 

545 natural fibrous tissues, and may degenerate further. Fatty degeneration ; fat 
formed in the proper tissue of the parts, muscular, fibrous, and cellular ; 
occurs under the same circumstances as fibrous degeneration, but in more 
cachectic subjects. Fatty liver ; appearance ; subjects ; cause. General fatty 
degeneration; subjects of it. Dr. George Johnson's views of Bright's kid- 
ney. Other examples of fatty transformation. Observations of Mr. Gulliver 
and Dr. Davy. Probably a chemical process like the formation of adipocire. 
Circumstances disposing to the general disorder; as affecting particular organs; 
often preceded by a cacoplastic deposit; always indicates a degradation of 
material. Analogy to vegetable matter. Effects. Examples. 

546 Calcareous degeneration; tissues most liable to it ; a chemical process or petri- 

faction; manner in which this occurs; produced spontaneously in old age, 

547 or as a result of inflammation. Effects. Treatment of degenerations. Means 
of sustaining vital powers. Hygienic measures. Tonics. Alteratives. Mine- 
ral waters. Removal of local disorder. 

Treatment of fibrous and granular degeneration; of fatty; of calcareous. 

Section VI. — Deposits in or upon Texture - p. 294 — 315 

548 Definition of deposits. Nature. Division. 

549 Euplastic deposits. Cicatrices. Reparation effected by three modes : union by 

550 first intention; adhesive inflammation; granulations. Dr. Carpenter's account 
of the organization of cicatrices. Observations of Mr. Travers. Reparation 

551 by blood. Remedial measures. 

553 Cacoplastic and aplastic deposits. Examples of the former: structure; causes, 

554 general and local. Cirrhosis. Granular degeneration. Structure. Semi- 

555 transparent, gray, and tough tubercle : a degraded kind of lymph. Connec- 

556 tion with other cacoplastic deposits. Tendency of cacoplastic deposits to 
contraction. Examples; effects ; intimate nature. Degeneration into aplastic, 

557, 558 the common tendency of tubercle, analogous to fibrous and granular and fatty 
degeneration. Form of tubercle. Causes. Microscopical and chemical 
character of granular tubercle. Opaque change indicates aplastic degenera- 

559 tion ; causes of this change. Primary aplastic deposits ; proof of degraded 

nutrition; yellow tubercle, maturation and softening: the converse of con- 
traction. Increase of fat in softened tubercle. Softening of tubercle attended 
by the formation of a material offensive to the system. Changes of tubercle 

560, 561 from adjoining textures. Quiescence of tubercle; spontaneous changes, in- 
duration ; plastery and petrifactive change, absorption of tuberculous matter. 

562 Causes of cacoplastic and aplastic deposits; congestion; chronic and asthenic 
inflammation; degraded plasma of the blood with defect of red particles. 

563 Seat of tubercles. Reasons of the liability of the lungs considered. External 

564 or exciting causes of tubercles ; operation explained. 

565 Treatment of cacoplastic and aplastic deposits. Elements to be considered. 

566 1. Disordered condition of the blood and its causes. Remedial measures. 

2. Disordered distribution of the blood and its causes. Remedial and preventive 
measures. 

567 3. Deposits already present; their effects and changes. Medicine of little 

effect; why? Mercury; alkalies; iodides; sarza; tonics. Solvents? caustic 

568 alkalies, acetic acid, naphtha, fixed oils. Cod liver oil. Theory of its bene- 
ficial operation. Means which promote absorption. External counter-irrita- 
tion. Nitric and hydrochloric acids, &c. 



CONTENTS. 



xxi 



Paragraph. 

Morbid Growths. 

569 Definition. Names and divisions. Analogous and heterologous, &c. 

Section VII. — Non-malignant Growths - - p. 315 — 321 

570, 571 Definition. Serous cysts. Distinguished from enlarged natural sacs. Encysted 

572 tumors. Hygroma. Haematoma. Steatoma. Lipoma. Atheroma. Forma- 

573 tion of these. Contents. Complex cystiform tumors. Sarcoma. Fibrous 
Adipose. Chondroma. Erectile tumor, Dr. Hodgkins's view of the cysti- 

574 form origin of tumors. Pathological cause of morbid growths : altered vital 

575 property of molecules. Hydatids. Proofs of separate vitality; nature and 

576 origin ; situations ; death ; aplastic and fatty deposits around them. Echino- 
577, 578 coccus. Cysticercus. Distoma. Medical treatment of morbid growths, and 

their effects. 

Section VIII. — Malignant Growths p. 321 — 333 

579 Definition. Character of malignancy; varies in degree. 

580 Carcinoma the generic term. Varieties traced to different degrees of activity 

581 of cancerous matter. Some acute, some chronic. Elementary structure of 

582 cancer: cells; forming fibres, &c. Disposition to grow at expense of nutri- 
tion. Parasitic nature 1 germs or ova. Experiments of Langenbeck. Local 
origin of cancer as a modification of nutrition. Dr. Hodgkins's view. Prac- 

583 tical deductions from pathology of cancer. Mode of origin. Varieties of 
cancer explained by difference in quantity and activity of germs ; and activity 
of nutrition in adjoining textures. Scirrhus is the chronic form. Symptoms; 
tendencies. Open cancer : destructive effects on part, and on whole frame. 

584 Pancreatic, mammary, lardaceous, and solanoid, intermediate forms of cancer. 

585 Mode of growth. Encephaloid cancer the acute variety ; in parts and sub- 

586 jects where nutrition is active. Cause of rapid growth of encephaloid dis- 
ease. Colloid cancer. The cancerous element in a separate form. Other 
varieties from form, &c. 

587 Melanosis. Varieties. Peculiar black matter, its nature. 

588 Treatment of malignant growths. Indications. 1. To extirpate them ; 2. To 
589, 590 retard their development; 3. To counteract their effects. Means of attempt- 
ing the fulfilment of these. 

Section IX. — Disorders or Mechanism p. 334 

591 Changes in mechanism, elements of disease. Examples. 

592 — 595 Dilatation. Contraction. Rupture and laceration. Displacement and com- 
pression. Contortion. 



CHAPTER V.— CLASSIFICATION, SYMPTOMS AND DISTINCTION OF 

DISEASES. 

Section I. — Nosology - - - - p. 335 — 337 

596, 597 Definition of special diseases. Methods of classification. 

598, 599 Symptomatic. Methods of Sauvage, Cullen, &c. Correct pathology the true 
600 foundation of natural classification. Definitions of disease with reference to 

pathology. 

Section II. — Semeiologt and Diagnosis p. 338 — 371 

601, 602 Definition of symptoms and signs. Physical signs. Examples. Those of dis- 
ease known by comparison with healthy standards. Standard of symmetry. 

603, 604 Anatomical standard. Physical signs explained by physical laws. Vital 

605, 606 symptoms. Called also functional and physiological, general and rational. 

607 Examples. Sources of symptoms. Pulse. Skin. Tongue. Stools. Urine. 

[Methods of pursuing the study of semeiology. Signs derived from the 
exterior of the body; from the head, neck, and face; the throat; thorax; ab- 
domen; genital organs; extremities; nervous system; respiratory system; 



XXII 



CONTENTS. 



Paragraph. 

circulatory system; digestive system; from the urine; from the cutaneous 

609 exhalation; from animal heat.] Knowledge of pathology the best key to 

610 symptoms. Statistics a temporary substitute. Respective value of physical 
signs and vital symptoms. Division and nomenclature of symptoms. 

611, 612 Diagnosis defined. How founded. Division into general and special. Diag- 
613, 614 nosis, illustrated by problems, and modes of solution. Need of every branch 
615 of medicine in diagnosis. The test of ability and knowledge. Methods of 

examination with regard to diagnosis, prognosis, and practice. 



CHAPTER YL— PROGNOSIS.— FOREKNOWLEDGE OF RESULTS OF 

DISEASE. ... p. 372—389 

616 Definitions. Prognosis empirical or rational. Empirical that of infant medicine. 

617 Prognostics of Hippocrates. Good and bad signs. Rational prognosis de- 

618 scribed and exemplified. Circumstances from which prognosis may be 

619 formed, 1, relating to the subject; 2, to the disease; 1, age of the subject; 
sex; temperament; previous diseases; present diseases; previous habits, 
condition of the patient at the time of the attack. 

620 2. Of the disease. The cause, situation and nature, extent and progress; the 
621, 622 character of the symptoms. Good symptoms. Bad symptoms, signs of im- 
pediment to a vital function, and approach of one of the modes of death. 

623, 624 Operation of all die modes of death on the blood, proved. Modes of death 
arranged in table. 

625 Death by Syncope. By spasm of the heart. Causes: by loss of irritability: 

causes, poisons, diseases : symptoms of approach. 

626 Death by Asthenia. From diseases: symptoms of approach. 

627 Death by Asphyxia. Distinctions. Symptoms. Causes. Varieties. 

628 Death by Coma. Causes: symptoms. Combined with excitement of the 
medulla. How does coma cause death? Medullary symptoms the most 
serious. 

629 — 631 Death by Paralysis. Injuries to the medulla, to the different nerves of respira- 
tion, to the different nerves. Examples. Paralysis of spinal nerves with 

632 and without injury to the cord. With injury of cord itself, symptoms and 
fatal tendencies. 

633 Death by Kecrcemia. Explanation. Proofs of death of the blood. Mode of 

634 spreading death to other parts. External causes of necraemia. Vital resist- 
ance to its causes. Symptoms. 

635 Mode of elimination of causes of necraemia. Intrinsic causes of necrarnia. 
636 — 638 Symptoms of death by necraemia. Slow deaths, more general. 



CHAPTER VII— PROPHYLAXIS AND HYGIENICS. p. 390—423 



639 Definitions. Prophylaxis connected with special pathology. Hygienics refer to 

640 means of resisting disease generally, and to means which maintain the gene- 
ral health. Subjects for consideration enumerated. 

641, 642 Food. Purposes of; essentials of wholesome food. Wheaten bread ; unfer- 
mented bread. Meat : use and abuse of cooking. Varieties of meat, and 
their constituents. Fish : broths and soups ; eggs and milk ; cheese. Vege- 

643 tables. Choice of food and hour of meals. Breakfast and luncheon, dinner, 

644 tea, supper. Regularity in the hours of meals. Injury from long fasting. 

645 Clothing. Purposes. Provisions for alteration in the covering of the lower 

646 animals: according to season, weather, and temperature. Materials of dress. 

647 Objects in selecting them. To protect from cold, from currents of air, from 

648 dampness and dryness. Cautions in changing winter for summer clothing. 
649, 650 Summer clothing. Silk vestments, electric influence. Cases requiring addi- 
651 tional warm clothing. Coverings for the head. Various cautions. 



CONTENTS. 



XX1U 



Paragraph. 



652 Air and temperature. Beneficial effects of pure air; of change of air, seaside 

653 and inland. Traveling: high winds. Dry air; its ill effects; modes of pre- 

654 venting them ; causes ; soil ; winds. The sirocco ; effects. Damp air. Effects ; 
mode of operation. Cold and damp air; effects. Causes of damp air; 
winds, soil, dwellings. Marine humidity. Protective and counteractive 

655 means. Temperature; average most healthy. Causes of the oppressiveness 
of heated rooms. Salutary influence of cool air. Cases requiring additional 

656 warmth. Mr. Jeffery's respirator. 

657 Ventilation. Modes of .ventilating in winter and summer. Dr. Arnott's princi- 
658, 659 pies and contrivances. Supply of warm air. Forces used in ventilation. 

Agents for purifying air. 
660, 661 Bodily exercise. Beneficial effects of moderate exercise. Directions and cau- 
662 tions regarding exercise, according to age, strength, occupation, &c. Times 

for taking exercise. 
663, 664 Cautions as to amount and kinds of exercise. 

665 Mental occupation. Moderate and equal exercise of mental faculties beneficial. 

666, 667 Adaptation to age; in infancy; mental education and discipline: in youth; 

668 in maturity. Body and mind to be equally exercised; evil results of neglect- 

669 ing, and good effects of observing this rule. Variation of occupation invigo- 
rates the mind. 

670 Sleep. Effects and nature of healthy sleep. Symptoms : gaping and yawning. 
671,772 Circumstances which promote sleep: those which prevent or disturb it. 

673 Evil consequences of want of sleep. Directions to bad sleepers. Means of 
inducing sleep : Mr. Gardner's ; the author's ; Dr. Franklin's, &c. Reasons of 

674 their failure. Amount of sleep proper; varies with age, sex, strength, occu- 

675 pation, &c. Sleep to be limited, especially in certain cases. 

676 Excretion. A proper subject for hygienic rules ; depends on due activity of 

677 many functions. Intestinal excretion. Importance of punctuality and time 
67S for its evacuation. Various aids; in diet, exercise, by habitual aperients; 

679 their safety and efficacy when needed. 

680 Urinary excretion ; its importance. Amount and quality varies with diet, ex- 

ercise, &c. Cold water and other diuretic drinks. Propriety of timely but 

681 not too frequent evacuation. Excretions of the skin not fully known ; objects 

682 specified, promoted by various hygienic means, and specially by bathing, 
washing and friction : operation and useful application of these. 

6S3 [General hygienic rules for the sick. Dry and well-ventilated apartments. Tem- 

perature of the sick room. Light. Fumigations. Risk of moving patients. 

684 Cleanliness indispensable. Mode of changing the linen of patients. Auxiliary 

means to receive the excretions and prevent pressure. 

685 Food. Amount of nourishment necessary. Rule for its administration. Inju- 

dicious use of food. 

686 Removal of the excretions. 

687 Repose and quiet. 

688 Sleep. Manner of provoking it. 

689 The sensations. Emotions. Intellectual faculties. Conversation. Necessity 

of attention and sympathy to obtain the confidence of the patient. The fear 
of death. Propriety of communicating to patients their state. 

690 Hygiene of chronic diseases/] 



APPENDIX. 

Chemical pathology of gout and albuminuria. Additional facts proving the 
presence of lithic acid and urea in the blood, and their deficiency in the 
urine. Cure of albuminuria ----- p. 424 

Dr. Garrod's researches and theory on the causes and treatment of scurvy. 
Corroborative facts - - - - - - p. 425 

Dr. Simpson's discovery of the use of chloroform vapor as an anaesthetic agent : 
its mode of action ; cautions as to its employment - - p. 426 

The Study of General Pathology the proper Foundation op Practical 
Medicine, (being a portion of an Introductory Lecture delivered in 1 842) 

p. 428 



xxir 



CONTENTS. 



State of practical medicine as a study and as an art. Favor shown to empiri- 
cism by the public. Irksome and difficult character of the study of medicine 
as usually taught. Insufficiency of empirical and nosological medicine. Some 
knowledge of general pathology at length gained in practice. Need of gene- 
ral pathology in the study and practice of medicine. What is general patho- 
logy'? Contributions from all departments of medical science, especially 
clinical medicine. General pathology the proper introduction to special 
pathology. Where principles fail, experience must be the sole guide. Noble 
nature and objects of medicine the best encouragements to its careful study. 



PRINCIPLES OF MEDICINE. 



EXPLANATION OF THE SUBJECTS OF THE WORK. 

1. The Principles, Elements, or Institutes of Medicine com- 
prise those leading and general facts and doctrines regarding disease 
and its treatment, which are applicable, not to individual cases only, but 
to groups or classes of diseases. The same branch of medical know- 
ledge is also designated by the term General Pathology and Thera- 
peutics, to distinguish it from special pathology and therapeutics, or the 
theory and practice of medicine in relation to individual diseases. 

2. The principles of medicine may be deduced in part from a know- 
ledge of animal structure and function, (anatomy and physiology,) con- 
joined with an acquaintance with the agents which cause and remove 
disease ; but chiefly they are derived from a generalization of facts ob- 
served in an extensive study of disease itself, and its effects, in the liv- 
ing and in the dead body. But so far as they have been ascertained, 
they become more intelligible to the student if explained synthetically, 
by describing first the causes of disease, then their operation on the body, 
and lastly, the resulting changes in function or structure which consti- 
tute disease in its more elementary forms. 

3. Etiology, or a knowledge of the causes of disease, will intro- 
duce us to their effect — disease itself; the nature and constitution of 
which will then be considered under the head of pathogeny, or pa- 
thology proper. As this last subject is the chief one to be treated, it 
will occupy the greater part of the work, and it will be combined with 
such an elementary view of the principles of treatment (general thera- 
peutics), as reason and experience may supply. 

4. A short general view will afterwards be given of the phenomena 
of disease, (semeiology,) the division and classification of disease, (nos- 
ology,) their distinction, (diagnosis,) their result, (prognosis,) and their 
prevention, (prophylaxis and hygienics.) 



definition of disease. 

5. The reader is supposed to be acquainted with anatomy and physi- 
ology : without a knowledge of these, we cannot proceed even to a defi- 
2 



18 



EXPLANATION OF THE 



nition of disease. Disease is known only by comparing it with the 
standard of health, which it is the object of anatomy and physiology to 
describe. 

Health consists in a natural and proper condition and proportion in 
the functions and structures of the several parts of which the body is 
composed. From physiology we learn that these functions and struc- 
tures have to each other and to external agents certain relations, which 
are most conducive to their well being and permanency ; these constitute 
the condition of health. But the same knowledge also implies that func- 
tion and structure may be in states not conducive to their permanency 
and well-being; states which disturb the due balance between the seve- 
ral properties or parts of the animal frame ; and these states are those 
of disease. For example, physiology, as well as experience, teaches us, 
that in health the digestion of food is easy and comfortable. But when, 
after food is taken, there are pain, uneasiness, sickness, eructation, flatu- 
lence, or the like, we know that the function of digestion is changed 
from the healthy standard — is diseased ; and if this diseased function con- 
tinue long in spite of remedies which usually correct it, and if, on exam- 
ining the abdomen, we find at or near the epigastrium a hard tumor, 
which anatomy teaches us is not there in health, we know that there is 
also diseased structure. 

6. We find, then (§ 5), that there is disease of function, known by its 
deviation from a standard furnished by physiology ; and disease of struc- 
ture, which we recognize by a standard supplied by anatomy (§ 5). 
These varieties of disease may be, and very commonly are, combined : 
there is seldom structural disease without some disorder of function ; and 
in many instances functional disease is, or will be, accompanied by 
change of structure. 

7. Looking, then, to anatomy and physiology as standards, w r e may 
define disease to be, a changed condition or proportion of function or 
structure in one or more parts of the body. 

8. The standard of health is not, however, the same in all individuals : 
that which is health to one may be disease to another. Thus if we in- 
stance individual functions : — The healthy pulse in adults averages from 
70 to 80; yet there are some in whom 90 or 100 is a healthy pulse. 
Some persons fatten on a quantity of food on which others would starve. 
The animal functions, muscular strength and activity, nervous sensi- 
bility, and the sensorial powers, vary still more in different individuals, 
yet all within the limits of health : and, what is health in one, would be 
decidedly morbid in another. Such unusual proportions of certain struc- 
tures or functions constitute varieties of temperament ; and although they 
can scarcely be called morbid, yet they certainly give, as we shall after- 
wards see, a proclivity to disease. Thus a predominance of the func- 
tions of the nervous system, sensibility and excitability of the excito- 
inotory nerves, constitutes the nervous temperament, which is compatible 
with perfect health, although it predisposes the individual to diseases of 
the nervous system. A preponderance of the nutritive functions renders 
a person stout and bulky, although in perfect health ; but it carries with 
it a risk of exceeding the bounds of health, and of inducing plethora and 
obesity, which, as they interfere with the well-being and order of the 



SUBJECTS OF THE WORK. 



19 



bodily functions, constitute disease. But short of these degrees which 
are morbid, the functions and structures of the body present, in healthy 
individuals, a considerable variety in energy and development. 

[All variations from regularity in the actions performed by livingbeings, 
constitute the phenomena of disease. The investigation of these pheno- 
mena, and the reduction of them to general laws, expressive of their con- 
ditions, is the object of Pathology. Here, as in the kindred science of 
Physiology, the study of all the conditions is requisite ; and hence we 
have to make ourselves acquainted on the one hand, with the characters 
of all the external agents which can produce a deleterious effect upon the 
living body, whether their operation be mechanical, chemical, or vital, as 
well as the results of the suspension, partial or complete, of the con- 
ditions by which its healthy action is maintained. We have, too, to in- 
vestigate the changes of structure which manifest themselves in the body 
itself, and the countless variety of secondary results which arise from any 
disturbance of its train of actions. The Pathologist sets out with en- 
deavoring to determine the individual phenomena of diseased action, and 
when he has collected these in sufficient amount to serve as the basis of 
an induction, he attempts to ascertain the conditions common to all, and 
hence to arrive at their laws. The general principles of Pathology can 
only be founded on a knowledge of the elementary phenomena of dis- 
ease. The ars medendi, or the practice of the healing art, is based on 
the ratio medendi, or its theory. Were the science of Pathology more 
perfect, the rules deduced from its general principles would be of easier 
application, and would require only correct observation of the circum- 
stances which called for their employment. — C] 



CHAPTER I. 

ETIOLOGY. — ON THE CAUSES OF DISEASE. 



SECTION I. 

NATURE AND DIVISION OF CAUSES. 

9. Causes of disease are those circumstances which essentially pre- 
cede it, and to the operation of which its occurrence is due. In many 
instances, these circumstances elude our observation. In many others, 
the true cause, if apparent, is combined with other antecedent circum- 
stances which have no share in producing the disease, and yet are liable 
to be mistaken for causes. These circumstances are to be sifted and 
the true cause discovered, only by the attentive observation of large 
numbers of cases, in which disease is produced. The non-essential cir- 
cumstances will then be found to be sometimes absent, and that which 
is always present may be fairly regarded as the cause. But this, as be- 
fore stated, sometimes eludes observation ; and both in this case and in 
elucidating the operation of circumstances supposed to act as causes, the 
most useful knowledge may be obtained from an investigation of the ul- 
timate nature of disease itself, which will often throw light on the cause 
which has induced it. Thus it was long a matter of doubt whether the 
itch could be engendered from filth, as well as from contagion ; but 
since microscopic investigation has discovered the existence of the itch- 
mite, no doubt remains that this insect is the only essential cause of the 
disease. 

10. The causes or circumstances inducing disease may be intrinsic, 
or existing within the body, independently of any obvious external in- 
fluence ; or they may be extrinsic, having their origin without the body. 
As examples of intrinsic causes may be mentioned excess or defect of 
some function, as irritability, or of some constituent of the body, as the 
blood. Extrinsic causes are very numerous ; comprising all the external 
agencies which can operate on the body or mind, such as temperature, 
air, moisture, food, poisons, mechanical and chemical influences, sensual 
impressions, &c. &c. 

11. A great variety of agents and circumstances may thus act on the 
body so as to produce disease ; but in most instances, there is not that 
uniform and constant relation between these as causes, and the diseases 



PROXIMATE AND REMOTE CAUSES OF DISEASE. 



21 



as effects, which we might expect from the analogy of causation in the 
simpler sciences. In chemistry or in mechanics, effects certainly and 
uniformly follow causes ; in physiology or pathology, no doubt, effects 
also ensue; but whether these effects shall be manifest as disease or not, 
will depend on many circumstances, of which we often cannot take cog- 
nizance. It is true that when the causes resemble and act like those of 
physics or chemistry, their proper effects will not fail to ensue. Thus, 
a cutting instrument, a red-hot iron, or a corrosive liquid, will not fail to 
produce disease, because its operation is so energetic as to overcome all 
vital properties by physical and chemical force, and disorder must fol- 
low. Further, certain poisons and other potent agents, which act on 
without destroying the vital properties of living parts, may also, if of 
sufficient strength, pretty constantly produce morbid effects. Thus, 
opium, taken internally, causes somnolency ; tartar emetic excites nausea 
and vomiting ; cantharides applied to the surface induces inflamma- 
tion, &c. 

12. But the common causes of disease are seldom of this decided and 
positive character ; they are often present without disease ensuing ; and 
they are known to be causes only because disease is observed to ensue 
in a greater number of cases when they are present than when they are 
absent. Thus, improper food is a cause of indigestion, and exposure to 
cold is a cause of catarrh; yet many persons eat unwholesome food with- 
out suffering from indigestion, and many are exposed to cold without 
"taking cold." But those who do suffer from indigestion observe that 
they do so more after taking improper food ; and those who are affected 
with catarrh can often trace it to exposure to cold. The reason of this 
uncertainty of action is chiefly in various powers by which the body re- 
sists the morbific influence ; which powers vary much under different 
circumstances. The failure or irregular operation of this power consti- 
tutes one predisposition to disease. 

13. Causes of disease were formerly divided into remote and proxi- 
mate : the remote include both the predisposing and the exciting causes, 
the only circumstances now considered as causes. They were called 
remote, not because they are distant or not in the body, but because they 
are not, like the proximate cause, a constant and present part of the dis- 
ease. The term proximate cause was used by Cullen (after Gaubius) to 
represent the pathological condition, or essential bodily change, on 
which the symptoms depend ; and it was called a cause of the disease, 
because diseases were by him defined to be an assemblage of symptoms. 
But this essential bodily change is rather a part of the disease than a 
cause, and must be considered under the head of pathology. Discard- 
ing, then, the term proximate cause, we have only to consider the pre- 
disponent and exciting causes. 

14. The co-operation of both these kinds of causes is generally neces- 
sary to produce disease. A number of persons are exposed to cold : one 
gets a sore throat ; another, a pleurisy ; another, a diarrhoea ; another, 
some form of rheumatism ; and a fifth escapes without any disease. All 
five were exposed to the same cause, yet it acted differently on all. The 
four first were predisposed to the disease, which attacked them as soon 
as it was excited by the cold. The fifth had no predisposition; the excit- 



22 



ETIOLOGY- — CAUSES OF DISEASE. 



ing cause was therefore powerless ; it was insufficient without the pre- 
disposing cause ; as in the other cases, the predisposition was insufficient 
until the exciting cause, the cold, was applied. 

15. In some cases, however, where sufficiently strong, what is in a 
smaller degree a predisposition, in a greater degree constitutes a sole 
cause of disease (§ 11): thus a person with a very weak stomach always 
has indigestion, whether an exciting cause be applied or not. So like- 
wise exciting causes, if sufficiently strong, may produce disease without 
predisposition : thus a person not predisposed to indigestion may be 
pretty sure to earn it, if he take a sufficient quantity of fat, raw cucum- 
ber, pickled salmon, or any such indigestible matter. Take another 
example. A healthy person living in a marshy district may not get an 
ague, until he becomes debilitated by any cause, such as cold, or fa- 
tigue : then the poison will act. But without his being thus weakened, 
if the exciting cause be made stronger by his sleeping on the very marshy 
ground itself, then the poison may act without predisposition, and the 
ague begins (§ 12). 

16. The consideration of these facts throws some light on the nature 
of many predisponent causes. There is, in organized beings, a certain 
conservative power which opposes the operation of noxious agents, and 
labors to expel them when they are introduced. The existence of this 
power has long been recognized, and in former days it was impersonated. 
It was the archceus of Van Helmont ; the cmima of Stahl ; the vis medica- 
trix naturce, of Cullen. But without supposing it to be aught distinct 
from the ordinary attributes of living matter, we see its frequent opera- 
tion in the common performance of excretion : in the careful manner 
in which the noxious products of the body, and offending substances in 
food, are ejected from the system ; in the flow of tears to wash a grain 
of dust from the eye ; in the act of sneezing and coughing to discharge 
irritating matters from the air passages ; and in the slower, more com- 
plicated, but not less obvious example of inflammation, effusion of lymph, 
and suppuration, by which a thorn or other extraneous object is removed 
from the flesh. 

17. This vis conservatrix (§ 16) is alive to the exciting causes of dis- 
ease ; and in persons in full health, it is generally competent to resist 
them. How it resists them will depend on what they are. For in- 
stance : — Is cold the cause ? This throws the blood inwardly ; which, 
by increasing the internal secretions, and exciting the heart to increased 
action, establishes a calorific process, which removes the cold. Is the 
cause improper food ? The preserving power operates by discharging 
this speedily by vomiting or by stool. Is it a malarious or contagious 
poison ? It is carried off by an increase of some of the secretions. But 
if this resisting power (§ 16) be weakened, locally or generally, or if 
the exciting cause be too strong for it, then the cause acts, and disease 
begins (§ 15). 

18. In the cases hitherto noticed, predisponent causes consist in ab- 
sence or deficiency of power (§ 16), rather than the existence of any- 
thing positive : but sometimes predispositions depend on something posi- 
tively wrong in function or structure, which alone may scarcely amount 



PREDISPOSING CAUSES OF DISEASE. 



23 



to disease ; and this error may be congenital, or hereditary, or acquired 
from previous disease. 

19. It must be observed that predisponent causes operate chiefly 
through the constitution, or some of its powers ; hence they are often 
called constitutional or internal causes, in contradistinction to the excit- 
ing causes, which are more commonly external. But these terms are 
objectionable, because not always applicable. Sometimes the term pre- 
disposing is also inappropriate, as in the following instance. Several 
persons are exposed to a malarious or infectious poison : some of these 
afterwards suffer much from fatigue or privation ; they then begin to 
show the effects of the poison : others who have not suffered this second 
trial, escape unhurt. The poison has entered the system of both ; the 
last resist its influence ; the subsequent weakening reduces the powers 
of resistance in the first class, and exposes the system to the exciting 
cause: but occurring after, it cannot be said to predispose. Hence, un- 
der such circumstance, the fatigue or privation is called the determining 
cause. 

The frequent inapplicability of the terms under which the causes of 
disease are classified, suggests the truth that these divisions of causes 
are rather conventional and convenient, than natural and philosophical. 
The true, simple view r of causes, is that they are circumstances inducing 
disease. If strong, one such may be sufficient: if weak, two, three, or 
more may be required to operate together, or in succession, before that 
change of function or structure, which constitutes disease (§ 8), ensues. 
Which of these several circumstances respectively disposes, excites, or 
determines, and would therefore come under the divisions that I have 
endeavored to explain, will often be very difficult to decide. 



SECTION II. 

PREDISPOSING CAUSES OF DISEASE. 



20. Predisposing causes of disease commonly consist of various cir- 
cumstances which influence the functions or structures of the body in an 
unfavorable manner, yet short of actual disease. It will be useful to 
illustrate them by examples, which I will group under the following 
heads. 

I. Debilitating Influences. 

II. Excitement. 

III. Previous Disease. 

IV. Present Disease. 

V. Hereditary Constitution. 

VI. Temperament. 

VII. Age. 

VIII. Sex. 

IX. Occupation. 



I. Debilitating Causes of Predisposition are the most numerous of 



24 



PREDISPOSING CAUSES OF DISEASE. 



any. So we might expect from the fact that constitutional strength 
generally implies power of resisting disease (§§ 16, 17). The weak- 
ness which renders the body liable to disease is that especially which 
enfeebles the heart, and impairs the tone of the arteries : it is often ac- 
companied with an unusual susceptibility of the nervous system, which 
increases the liability of the body to suffer. The following are the chief 
of this class. 

21 (a). Imperfect nourishment, from defect either in the quantity or 
quality of the food, or from incapacity of the digestive powers. This in 
itself may cause many diseases, particularly of digestion and nutrition ; 
but it also weakens the power to resist cold, and produces a liability to 
low fevers and inflammations, epidemic and contagious disorders. Thus 
the susceptibility of the body to cold and to infection, w T hen fasting, is 
generally acknowledged; and the rapid propagation of infectious dis- 
eases among an ill-fed population, such as the poor Irish, is too well 
known. 

22 (b). Impure air. — The injurious effects of this are apparent in the 
pallid, cachectic complexion of the inhabitants of crowded cities, even 
those who live well and regularly. How do they contrast with the 
ruddy countenances of the hardy and coarsely-fed mountaineer! So do 
they also in their liability to diseases, particularly to those of the organs 
of respiration, circulation, and nutrition.* 

23 (c). Excessive exertion of body or mind. — Exercise is beneficial 
to both body and mind ; but when in degree or continuance it exceeds 
what the strength can bear, or rest can recruit, the animal functions are 
exhausted, and lose their balance; muscular tone is impaired, nervous 
excitability takes the place of strength, the circulation fails, congestions 
ensue, the blood is not properly purified, and the various organs are on 
the brink of disease. It is thus that the fatigued mind or body is pecu- 

* [One of the most fertile sources of infantile disease, is a want of a due supply of pure 
and wholesome air ; the effects of which are sure to manifest themselves, though often ob- 
scurely, and at a remote period. It is physiologically impossible for human beings to grow 
up in a sound and healthy state of body and mind, in the midst of a close, ill-ventilated at- 
mosphere. Those that are least able to resist its baneful influences, are carried off by the 
diseases of infancy and childhood ; and those whose native vigor of constitution enables them 
to struggle through these, become the victims, in later years, of diseases which cut short their 
term of life, or deprive them of a large portion of that enjoyment which health alone can 
bring. This statement is supported by facts. A recent visitor to the Island of St. Kilda,the 
most northern of the Hebrides, states that eight out of every ten children, die between the eighth 
and twelfth day of their existence; in consequence of which terrible mortality the popula- 
tion of the island is diminishing, rather than increasing. This is due not to anything inju- 
rious or pernicious in the atmosphere of the island; for "its air is good and the water 
excellent; but to the filth in which the inhabitants live, and the noxious effluvia which per- 
vade their houses." The huts are small, low-roofed, and without windows, and are used 
during winter as stores for the collection of manure, which is carefully laid out upon the 
floor, and trodden under foot, till it accumulates to the depth of several feet. The clergy- 
man, who lives exactly as those around him do, except as regards the condition of his house, 
has reared a family of four children, all of whom are well and healthy; whereas, according 
to the average mortality around him, at least three out of four would have been dead within 
the first fortnight. At the end of the last century, in the Dublin Foundling Hospital, during 
a space of 21 years, ending 1796, out of 10,272 sick children, sent to the infirmary, only 45 
recovered. Deficient ventilation, from the crowding of the wards, was an efficient agent in 
this fearful result. (a) — C] 



(a) Carpenter's Animal Physiology, pp. 3, 4. 



DEBILITATING INFLUENCES. 



25 



liarly prone to suffer from causes of disease. Want of sleep has similar 
effects; and when the body is extremely exhausted, even sleep, which 
is nature's best restorer, is disturbed by the imperfect performance of 
circulation and respiration in the excess of weakness: hence a liability 
to insomnia and nervous excitement from exhaustion. 

24 (d). Want of exercise and sedentary habits generally, form another 
extreme which favors the production of disease. The healthy vigor of 
all the functions of the body and mind is best maintained by their equal 
and moderate exercise; and the torpor of inactivity renders them inca- 
pable of resisting the causes of disease. The muscular function, and 
with it the circulation of the blood, is the first to suffer; hence first slug- 
gish movements, and ultimately weakness of the heart and other muscles. 
The defective circulation is felt most at parts at a distance from the 
heart, hence cold extremities, dry skin, congested liver, with its frequent 
concomitants, hemorrhoids, torpid bowels, and indigestion: whilst the 
heart itself and the organs near it may be oppressed and injured by the 
load of blood in them, especially if the subject is plethoric; hence palpi- 
tation, dyspnoea, headache, vertigo, somnolency, dulness of the senses, 
&c. &c. In nervous subjects, convulsive affections may be promoted by 
the same inequality of circulation. The respiration being little exercised, 
the task of decarbonizing the blood is imperfectly performed, or falls more 
on the liver: hence the accumulation of fat in the textures, and the oc- 
currence of bilious derangements. From this statement it is obvious 
that sedentary habits, wmere extreme, may be equivalent to produce 
disease, and where existing in less degree, they promote its occurrence 
from Other causes, such as irregularities of diet, exposure to cold, violent 
exertion, &c. From such combination of influences arise various dis- 
orders of the digestive organs, heart, lungs, and brain, catarrhs, gout, 
rheumatism, calculous affections, diseases of the skin, &c. 

25 (e). Long continued heat. — The debilitating effects of this agent 
are exemplified in warm climates and seasons. Under its influence, 
the muscles, and with them the heart and arteries, lose power and tone ; 
the textures become relaxed ; perspiration is profuse : and internal organs, 
especially the liver, are too much stimulated by blood which has lost 
more than usual of its w T ater, and less of its hydro-carbon. Hence the 
disposition to bilious and liver complaints-, dysentery and cholera. 
[The action of heat is debilitating from the losses the economy sustains 
from the undue cutaneous secretions, and from the over-stimulation of 
the nervous system. This debilitating action of heat is increased when 
combined with moisture. Diseases of the gastrointestinal mucous 
membranes are more especially developed. Under the influence of these 
two agents combined — heat and moisture — there is a marked tendency 
in diseases to assume a typhoid or adynamic form. — C] Overheated 
rooms and excessive clothing likewise predispose to disease by their 
weakening and relaxing influence. [Warm clothing is a source of 
disease, and very often of the same diseases which originate in an ex- 
posure to cold. Overheated sitting and sleeping apartments, warm soft 
beds and bed clothing relax and weaken the frame, disposing to disorders 
of the renal, urinary, and generative organs, and render the system gene- 
rally much more impressible to external injurious influences. A predis- 



26 



PREDISPOSING CAUSES OF DISEASE. 



position is thus induced not only to catarrhs, inflammations, affections of 
the lungs, and rheumatism, but to irregularity in the menstrual discharge. 
It has been remarked that the females of Holland, who generally use very 
warm clothing, warm apartments, warm beds, and footstoves, are subject 
to excessive menstruation and leucorrhcea. — C] It may be remarked 
that most of the diseases of hot climates and seasons occur rather at the 
termination of the heat than during its steady prevalence, and that there- 
fore it predisposes to, rather than excites, the disease, which is the im- 
mediate effect of cold, or of irregularity of diet, or of malaria. Thus the 
bilious cholera of this country occurs chiefly in the early autumn, when 
the cool of the evening forms a contrast with the heat of the day. The 
chill suddenly arrests the perspiration, and throwing the blood inwardly, 
oppresses internal organs, especially the liver, whose vital energies have 
been exhausted by the influence of the previous heat: hence coldness of 
the surface, and congestion of the liver and portal system, ending in flux, 
cholera, diarrhoea, dysentery, &c. 

29 (f). Long- continued cold. — The experiments of Chossat and others 
clearly prove cold to be a direct sedative, capable of reducing all the 
vital properties. Cold applied suddenly and for a short time, invigorates, 
because it is followed by a healthy reaction, in which the vital properties 
are exercised and exalted. But when long continued, its own sedative 
and debilitating effects are permanent : it weakens the circulation, espe- 
cially that of the surface, causes internal congestions, and directly lowers 
all the vital energies. Hence the most malignant forms of epidemic 
fever in this country are observed to prevail towards the close of very 
severe winters; and all diseases may then assume a typhoid type. This 
is observed chiefly among the lower orders, whose means do not enable 
them to protect themselves sufficiently against the inclemencies of the 
season. We have before adverted to the striking manner in which cold 
disposes the body to suffer from malaria. 

27 (g). Habitual intemperance with intoxicating liquors. — There is 
probably, in this country, no source of disease more fertile than this. 
Besides many which it excites, it predisposes the body to attacks of 
fever, erysipelas, dysentery, cholera, dropsy, rheumatic and urinary 
diseases ; and if it do not increase the proneness to inflammatory disorders, 
the habit of intemperance certainly disposes them to unfavorable termi- 
nations, and causes many a victim to sink after accidents and operations, 
which would be comparatively trifling in a sober subject. Nor can we 
wonder at the pernicious effects of this kind of excess, when we consider 
the weakened state of function and structure which stimulating drinks in- 
duce, especially in the organs which they most directly affect, the stomach, 
the liver, the kidneys, the heart, and the brain. We shall soon have 
to explain how such an unsound state of these organs peculiarly impairs 
the powers of the body to resist or throw off disease (§ 17). 

28 (/?■). Depressing passions of the mind, such as fear, grief, and de- 
spondency. — Many are the instances in which numbers, as well as indivi- 
duals, have escaped a prevalent disease, until depressed by some un- 
happy event or apprehension, and then they have fallen victims. Such 
was instanced in the ill-fated Walcheren expedition, and in many passages 
in the history of armies in pestilential countries. A defeat, a failure, 



DEBILITATING INFLUENCES. 



27 



or even bad news, made many succumb to the pestilence who had before 
escaped. It is a common remark, that when a contagious or epidemic 
disease prevails, those who take most precautions frequently suffer, 
because they are timid and fearful, whilst the stout-hearted and reckless 
are unscathed. [When the mental energies are depressed by fear, grief, 
anxiety, disappointment, &c, the powers of life are less able to oppose 
the debilitating causes of disease, and individuals, singly, or collective- 
ly, are, under such circumstances, especially liable to those disorders 
which are of a general or specific origin, as fevers, &c. There is nothing 
which more certainly predisposes the system to the operation of the 
exciting causes of fever, than the fear of being attacked by it. On the 
contrary, when the mind is elevated by success, hope, and confidence, 
or other exciting passions, depressing causes make little or no impression 
upon the constitution, and individuals thus circumstanced almost always 
escape from diseases which readily invade the fearful, the dejected and 
the disappointed. Indulgence of temper and passion not only predispose 
to disease, but frequently excite it, in the nervous, irritable, and san- 
guine temperament. Diseases of the heart, brain, liver, stomach, and 
bowels often originate in these sources. Uncontrolled passions of every 
description occasion a host of functional and structural disorders of the 
great viscera, whilst moderation of all the appetites, an equable state 
of mind, and the moderate excitement accompanying a well-regulated 
application to business or study, are among the best means of resisting 
the impression of injurious agents. — C] 

29 (i). Excessive and repeated evacuations, either of the blood or of 
some secretion. — The weakening effect of a large loss of blood needs no 
explanation; but the injurious influence of habitual losses or drains, if 
there be more than the system can repair, is still greater ; for the functions 
then become depraved as well as depressed, a state of cachexia as well as 
anaemia is induced, and a little cause may suffice to determine many states 
of disease. Various hemorrhages and discharges, menorrhagia, diarrhoea, 
leucorrhcea, and other fluxes, if in excess, reduce the powers of life and 
the capacity to resist disease. No secretion, however, weakens so much 
or so irreparably, when in excess, as that of semen. In many of the low r er 
tribes of animals, the males live till they copulate, and then die : the repro- 
duction of the species is at the expense of the individual. That our species 
is not wholly exempt from this law T of organized nature, is apparent from 
the fact that immoderate venery is known to produce extreme debility 
and premature decay, and to dispose the body and mind to various dis- 
eases. [Excessive sexual indulgence is a frequent predisposing cause 
of many diseases. Pulmonary and cardiac disorders, epilepsy, mania 
and other disordered manifestations of mind, not unfrequently occur, 
from the. condition of the system induced by the abuse of this appetite. 
It also leads to other maladies by depressing the vital energies of the 
frame, and rendering it more assailable to the common exciting causes 
of disease. — C] 

30 (j). Previous debilitating diseases. — It is well knowm that the body 
is unusually liable to disorder during convalescence from serious mala- 
dies. It is weak in all its powers; whilst the nervous system often ob- 
taining the ascendency which is common in states of weakness, renders 



28 



PREDISPOSING CAUSES OF DISEASE. 



the body unusually susceptible (§ 23); and improper food, exertion, ex- 
citement, or exposure to cold, may readily produce the former or some 
new complaint. Hence convalescence from a severe disease is a con- 
dition of health that requires peculiar care. The functions are just resum- 
ing their balance, and have neither the vigor of action, nor the power of 
resistance which is the attribute of robust health. The diseases which 
leave the body most liable to derangement are those ending in exhaus- 
tion, as continued fevers and protracted and severe inflammations. 

31. II. Hitherto we have considered only those circumstances which 
predispose to disease by their weakening influences (§§ 16, 17, 20). 
There are others of a somewhat opposite character, which favor the pro- 
duction of disease by a state of excitement or activity. Thus full 
living, without an adequate amount of exercise, may bring the circula- 
tion and other functions up to a high pressure degree of activity without 
producing disease ; in fact, there is a redundancy of health ; and there is 
more than usual capability of resisting those causes of disease which 
operate by depression, such as cold, malaria, infection, &c. But there 
is a predisposition to suffer from causes of additional excitement ; thus 
irritants applied, more readily induce inflammation; violent exertion may 
cause hemorrhages ; and in any organ the operation of a stimulus may 
heighten the actions to a pitch that is morbid (§ 5 — 8). So, also, unusual 
vascular activity in a part, when insufficient to produce disease, renders 
the part more liable to suffer from external causes. Thus the determina- 
tion of blood to the uterus and mammae at certain periods, renders them 
liable to disease at those times. Violent exertion makes the muscles or 
their fasciae peculiarly liable to rheumatic inflammation from the sub- 
sequent action of cold and damp. Excessive indulgence in a stimulant 
diuretic beverage, such as punch, renders the kidneys liable to inflam- 
mation or congestion on exposure to cold. Inflammation or irritation of 
the intestines is not a common effect of cold, except when these viscera 
are under the exciting influence of a purgative. The brain, if previously 
over-active from hard study, may be excited into inflammation by alco- 
holic stimulus or strong moral emotion. 

32. III. Proclivity to disease is not unfrequently caused by previous 
disease, independently of the weakening influence before noticed (§ 30). 
This is particularly the case with some inflammatory and nervous dis- 
orders. Thus, a child who has once had croup is very liable to its recur- 
rence. One attack of enteritis frequently predisposes to its recurrence. 
Convulsive disorders, such as chorea, hysteria, and epilepsy, are ex- 
tremely apt to recur; and the longer they have existed, the more difficult 
are they to remove, and the more ready are they to reappear on the 
application of any existing cause. This is what may be called a habit 
of disease, which is most important to prevent. There can be little 
doubt that the previous attack in all such cases leaves some change of 
structure or function (§ 18), which constitutes the predisposition, al- 
though this change may elude our means of detection. 

33. Under this head we may arrange many constitutional predisposi- 
tions to disease which are to be ascribed, not to a previous attack, but 
to the persistence in the system of a cause of that attack. Rheumatism, 
gout, gravel, many cutaneous diseases, dropsy, jaundice, and many 



PRESENT DISEASE. 



29 



others, may be quoted as examples. A person who has once suffered 
from any of these is very liable to a recurrence on the application of an 
exciting cause ; and this is because, although free from the first attack, 
he may not be free from some functional or structural imperfection (§ 18) 
which was the predisponent to that attack, and which may again be 
brought into operation by the addition of an exciting cause. In most 
of these cases, the constitutional defect is in some of the processes of 
assimilation or excretion, this defect being generally functional, but in 
some cases it is also attended with change of structure, especially in the 
great eliminating organs, the liver and the kidneys. When the tendency 
to the diseases under notice is acquired, it may be often traced to causes 
which peculiarly affect these organs, such as intemperance or irregularities 
of diet, sedentary habits, and scarlet fever. 

Nor can we separate from this class of constitutional causes (§ 32) the 
predispositions to many structural diseases, such as tuberculous and ma- 
lignant formations. Where such have once appeared, there is a tendency 
to the production of more, although this tendency may be latent until 
brought into activity by an exciting cause. In the following pages many 
arguments will be found in favor of the view that the disposition to these 
diseases is connected with errors in the functions of assimilation and ex- 
cretion. 

34. IV. Disease already existing in the body, even when itself 
latent, often predisposes to other disorders, independently of its weaken- 
ing effect (§20). Thus tubercles and other tumors, structural lesions 
of the heart and other organs, often induce irritations or obstructions of 
blood-vessels, which, if not themselves causing open disease, render them 
ripe for disorder from other causes. Thus a person on the occasion of 
violent bodily or vocal exertion is seized with profuse spitting of blood, 
which causes his death : on opening the body many tubercles are found 
in the lungs, although there had been no obvious symptoms of their ex- 
istence before the violent effort. Again, disease of the heart causing 
accumulation in the veins often leads to congestion of the lungs and 
liver ; and it may only require the addition of an exciting cause, such as 
sudden exertion or an excess in diet, to bring about an attack of asthma 
or jaundice. These are mere instances of causes coming into operation 
by accumulation. Granular disease of the kidneys, which impairs their 
excreting power, renders the body more liable to suffer from infectious 
and other poisons, and from other exciting causes of disease. 

35. The predisposing causes hitherto considered may be called acci- 
dental or acquired. There are others which are born with the individual ; 
and others which arise from circumstances of age or growth. All these 
may be supposed to depend on something defective or ill-balanced in the 
organization (§ 18), which is insufficient to manifest itself until wrought 
upon by an external exciting cause. 

36. V. Of the predispositions born with the individual, the most gene- 
rally acknowledged is hereditary tendency to disease. It is well 
known that scrofula, gout, rheumatism, epilepsy, mania, asthma, blind- 
ness, and deafness, run in families. That this depends on individual 



30 



PREDISPOSING CAUSES OF DISEASE. 



peculiarities transmitted from parents to offspring, appears from the fact 
that all children do not partake, or not alike, of the disposition. [Thus 
it has been observed that in constitutional syphilis, a first child born of pa- 
rents, one of whom has been infected, may be tainted with the venereal 
poison, whilst the second would be perfectly healthy, a third would be 
diseased, and a fourth sound ; thus alternating, as it were. Children 
born of gouty parents have escaped entirely the disease, but have trans- 
mitted it to their offspring, who have suffered from well-marked fits of 
podagra. — C] Nay, sometimes a whole generation is passed over, and 
the disease appears in a third. So, too, we see externa] organization, 
family likeness, differently stamped on different children of the same 
family. [The influence of hereditary transmission is proved by nume- 
rous and positive facts; indeed, peculiarities of configuration or feature 
are not more decidedly transmitted from the parent to the offspring, than 
constitutional taint, and certain pathological conditions. It is not sim- 
ply the influence of temperament which, endowed with the same pecu- 
liarities, tends to produce the same disease, but a settled, inherent 
disposition to such, or such pathological development, which may be 
found, even when the resemblance does not exist. Under this influence, 
the disorder may go on, being propagated from one generation to another, 
or it may stop short at one. But in the latter instance, it seems neces- 
sary that this influence should be exercised in a regular, invariable, and 
general manner; and in its expression great variety has been observed. 
Sex in some families would seem to modify the hereditary tendency, the 
females being attacked with one form of disease, and the males with an- 
other not analogous. This twofold effect of hereditary efficiency in the 
same family, w T ould appear to be the result of a double influence, one 
disorder being derived from the mother, and the other from the father. 
In cases when the father and mother suffer under different constitutional 
disorders, a sort of crossing often seems to occur; — the disorder of the 
father attacking the girls, whilst that of the mother appears in the males. 
Generally the hereditary pathological tendencies of the mother are more 
readily transmissible than those of the father. — C] 

It must not be supposed that hereditary proclivity to disease com- 
mences at birth. In a few instances, it is congenital ; but in the greater 
number it is developed by growth or some other circumstances in life. 
Gout, for example, is acknowledged to be hereditary. A parent has it 
in middle or advanced life : his son does not get it until about the same 
period, sooner or later, according to whether he lives freely or not. 
Here is something transmitted from father to son, yet not manifest in the 
son for forty or fifty years. [It has been observed that diseases deve- 
loped under the influence of hereditary predisposition, generally manifest 
themselves at an earlier age than that at which the same affection is or- 
dinarily developed, independently of this predisponent cause. 

There are other instances, and very curious and interesting they are, 
in which the children of a family succumb to a disorder of which the pa- 
rents have never exhibited any traces, when subsequently the father, or 
mother, or both, are attacked, and thus the point of departure of the dis- 
order, which had exercised a sort of anticipatory action on the offspring, 
is disclosed. This variety of hereditary influence has been frequently 



TEMPERAMENT AGE. 



31 



observed, and especially with reference to insanity, in which disorder the 
children are not unfrequently attacked before the parent. A well au- 
thenticated instance of the same manifestation in tubercular disease, has 
been recorded by a late authority. A young man of 19 years of age, of 
fine constitution and great muscular development, after a violent physi- 
cal exertion, was attacked with abundant haemoptysis, and shortly after- 
wards well-marked phthisis appeared, and he soon died. Neither his 
father nor mother bad exhibited any tuberculous tendency, or a young 
sister, the only remaining child. When she reached 19 years of age, 
the young sister was attacked with pulmonary tubercular disease, and 
succumbed ; and it was not for two years subsequently that the mother, 
53 years old, presented the first symptoms of consumption, of which she 
soon died, thus exhibiting the existence of an hereditary influence, whose 
effects had preceded the manifestation. — C] 

37. VI. Frequently, but not essentially, connected with hereditary con- 
formation, is the peculiarity of constitution called temperament, which 
certainly predisposes to particular diseases. Temperament consists in 
a predominance or defect of some function or set of functions (9). 

38. Thus the sanguine temperament implies an activity of the system 
which circulates red blood, and a rich proportion of red particles, manifest 
in the excitable pulse and flushing cheek of those of this temperament; 
and further evinced in their quick movements and lively disposition. 
This temperament gives a disposition to inflammation, determination of 
blood, and active hemorrhage (30). 

39. The phlegmatic or lymphatic temperament is the reverse of the 
sanguine : it occurs in those with weak pulse and languid circulation, 
cold extremities, and pallid skin, — there is a deficiency of red blood 
and of vascular action and tone (§ 9), and the proclivity is to w 7 atery 
fluxes, dropsy, and other chronic affections. 

40. In the bilious or melancholic temperament, which is commonly 
met with in persons of dark complexion and gloomy disposition, there 
is probably a defective action in some of the biliary or digestive organs, 
which are therefore the more liable to derangement (§ 9). 

41. The nervous temperament is externally manifest only by agitation 
or trepidation of manner; it seems to depend on an excess or want of 
proportion of some properties of the nervous system (§ 9), and it pre- 
disposes to the disorders called nervous, such as hysteria, nervous pains, 
spasms, &c. These temperaments may be variously combined. 

The word diathesis is often used to express a particular morbid tend- 
ency; thus we hear of the inflammatory diathesis, the scrofulous dia- 
thesis, &c. It is merely a term signifying disposition, without affording 
any clue to its true cause. 

42. VII. The last head of predisponent causes to be noticed, is age. 
The several changes in organization, as well as in external circumstance, 
which the animal frame undergoes at different periods of life, may naturally 
be expected to be attended with corresponding proclivities to disease. I 
proceed to enumerate a few of these, premising that some of the exam- 



32 



PREDISPOSING CAUSES OF DISEASE. 



pies maybe entitled to rank under the head of exciting causes of disease, 
as well as under that of predispositions. 

43 (a). In early infancy, the low calorific power of the body disposes 
it to suffer from the bad effects of cold (§ 17), whence the tendency to 
visceral inflammations. The skin is particularly liable to various erup- 
tions, in consequence of its tenderness, and the new and drying medium 
in which it is placed. The redness of new-born children is obviously 
the result of the action of the air; it is often a vivid erythema, followed 
by desquamation of the cuticle, and a yellow stain of the skin from ex- 
travasated hsematosin, which is erroneously thought to be a kind of jaun- 
dice. Strophulus and other papular eruptions often succeed, [with im- 
petigo of the face and eczema of the scalp; oedema of new-born children 
is peculiar to this period of life.— C] The comparatively virgin state of 
the alimentary canal at birth renders it peculiarly susceptible of disorder; 
and a similar trial may occur at the period of weaning; hence arise 
diarrhoea, vomiting, colic, waterbrash, atrophy, and other ailments con- 
nected with disordered digestion, [with that form of enteritic disease 
called cholera infantum, the great desolator of the infantile population 
of our northern cities. — C] The brain, excited by the novelties of the 
external world, becomes rapidly developed, and in its increased activity and 
growth, is liable to various diseases (§ 30) ; hence the proclivity to hy- 
drocephalus, convulsions, &c. The process of teething adds an irrita- 
tion, which, by its influence on the nervous system, the bowels, and the 
air passages, disposes them to disorder. [In early infancy, rachitism, 
with gangrene of the mouth, (cancrum oris,) the various forms of stoma- 
titis and angina, as well as diphtheritic inflammation of the larynx and 
trachea, are frequently met with. — C] 

44 (b). Childhood, or the age from infancy to puberty . — The functions 
most active are those which administer to growth: the organs of diges- 
tion and assimilation are therefore obnoxious to disorder (§ 32); hence 
derangements of the stomach and bowels, worms, infantile remittent, &c. 
The activity of the nutritive function gives a preponderance to the fibrinous 
or protein constituent of the blood ; and inflammations which may occur 
are often attended with the effusion of much plastic or albuminous mat- 
ter; hence the products of croup, tubercle, mesenteric disease, &c. The 
natural mobility (or activity of the excito-motory system) of childhood 
predisposes to chorea and kindred affections (§ 30). [At this epoch, 
too, tuberculous affections of the bronchial ganglia, mesentery, peri- 
toneum, and cerebral meninges, are of frequent occurrence, and present 
some peculiarities in their course and character, as do also some of the 
acute inflammations of the pulmonary organs, as bronchitis, pneumonia, 
the latter generally occurring in the form called lobular. Stridulous or 
crowing laryngitis, and hooping cough, with the eruptive fevers, as 
scarlatina, measles, and variola and its modifications, are diseases of 
childhood. — C] 

45 (c). Puberty brings with it many morbid susceptibilities, chiefly 
in the female sex, in which the important function of menstruation is to 
be established. Many and serious are the evils that are liable to be pro- 
duced by external causes, which check the development of this function. 
So also when established, this function has its nervous as well as its 



ADULT AGE. 



33 



vascular relations; and where it is irregular or disordered, a predisposi- 
tion is given to many maladies affecting the blood-vessels and their con- 
tents, the secreting organs, and the nervous system. 

[This is one of the most important periods of human existence, for during 
it the development of the organs of reproduction in the two sexes takes 
place, and the whole economy is brought to full perfection. The organs 
of respiration and of voice acquire their full growth and tone; the muscles 
their due proportion ; and the cerebro-spinal system its complex and won- 
derful organization. The instinctive feelings and emotions reach their 
utmost limits; and many of them, especially those relating to the sexual 
organs, acquire an ascendancy, and their indulgence becomes a cause of 
disease. From this source frequently spring impotence and the extinction 
of families ; the infliction, during after life, of many of the disorders which 
proceed from debility, and the exhaustion of the nourishment and vital 
energy of the various organs; innumerable nervous and convulsive 
maladies, as hysteria, epilepsy, neuralgia, chorea, melancholia, mania, 
idiocy, &c. ; diseases of the heart ; disorders of the digestive organs ; pre- 
mature alopecia, and old age; the formation of tubercles and the pro- 
duction of pulmonary consumption; and lastly, the transmission of weak 
and decrepid bodies and minds to the offspring, scrofula, rickets, maras- 
mus, hydrocephalus, &c. The pathological tendencies of this age are 
especially characterized by exalted action. At the approach and com- 
mencement of puberty, the glandular system is extremely prone to con- 
gestions and inflammations, particularly the lymphatic ganglia of the 
neck and axilla. Tubercles are rapidly developed in the lungs, and 
these organs are much disposed to acute and chronic inflammations of 
their substance and mucous surfaces ; pulmonary hemorrhage replaces 
the epistaxis of childhood, and in females dysmenorrhcea, protracted men- 
struation, amenorrhcea, leucorrhcea, chlorosis, and hysteria appear. — C] 

46 (d). Jit the termination of growth, there is another critical period. 
The cessation of that appropriation of nourishment for the increase of 
the body, that had hitherto been going on, may cause fullness of the 
vessels, and a disposition to hypertrophy, hemorrhage, and inflammation, 
in the more robust ; and in the cachectic, to morbid depositions, espe- 
cially of the tuberculous kind (§ 47). The same redundancy of the 
vivifying fluid in active circulation, gives that buoyancy of animal spirits 
and impulsive energy of feeling and strength, which are the characteris- 
tics of healthy youth ; yet this very exuberance of vital power, if not pro- 
perly controlled and balanced, may constitute a tendency to disease ; 
either directly, as where excitement rising beyond the limits of health 
borders on morbid action (§ 31) ; or indirectly, by leading to excessive 
exertion and subsequent exhaustion (§ 23). Youth is the age of sus- 
ceptibility to moral and physical impressions ; and therefore of liability 
to the disorders which these are capable of producing. 

47 '(e). Adult age can hardly be said to predispose to any diseases, 
unless it be those arising out of mode of life. It is commonly a period 
of steadier health, because the functions are more evenly balanced ; but 
if the mode of life be unfavorable, bad habits are apt to become estab- 
lished, and by their continuance to induce disease. Thus gout, gravel, 
rheumatism, indigestion, and various other disorders, are apt to occur 

3 



34 



PREDISPOSING CAUSES OF DISEASE. 



in middle life, because the predisposition to them is gradually engen- 
dered (§ 24) by some error in diet or regimen, too slight to excite dis- 
ease, but sufficient by accumulation to dispose to it, on the addition of 
an exciting cause. [As the age of fifty is approached, the circulation 
becomes more languid, particularly that of the venous system ; hence 
the frequency of venous congestions and visceral obstructions, with the 
numerous train of disorders they occasion, as hemorrhoids; inflammations 
of the great cavities, affections of the heart; apoplexy; paralysis; de- 
rangements of the stomach and bowels ; gout, rheumatism ; diseases of 
the urinary organs ; hysteria, and uterine disorders; hypochondriasis, and 
mental alienation. It is asserted that ataxic phenomena are more frequent 
accompaniments of severe disease at this than at any other period. — C] 

As age advances, such habits affect the organization, and accelerate 
those changes in the fabric, by which our existence is limited to a span 
of years. It would occupy too much space to enter into the details of 
all these changes, but some of the principal may be briefly noticed, as 
illustrating the weaknesses and liabilities of advanced age. 

48 (f). The changes which old age induces in the exterior of the 
body shows a failure of those functions which were active in youth. In- 
stead of muscles, fat and integuments being nourished in the equal pro- 
portions that give beauty as well as strength to the form in mature life, 
the muscles become thin and sinewy; fat becomes scanty, partial, or in 
excess; the integuments are loose and wrinkled, or fat and flabby; the 
joints stiffen, and the gait loses its firmness and uprightness. These 
changes in the textures of the body are attended, and probably induced, 
by altered proportions in the different parts of the vascular system. The 
pallid skin of age contrasted with the ruddy blush of youth, proves the 
diminished development of the capillary blood-vessels, that great system 
which sustains the life and nutrition of the body; hence much of the 
blood that in earlier age circulated on the surface, giving vigor and sen- 
sibility to all the external organs, and life and susceptibility to all out- 
ward relations, is now accumulated in the interior, and confines its vivi- 
fying and nutrient influence more to the internal functions and structures, 
thus tending to render the individual more isolated and selfish. But the 
blood thus abounding in the larger vessels is not equally distributed 
within them. The diminished capillaries intercept some of the force 
by which the blood is propelled through the arteries: hence this fluid 
stagnates and accumulates in the veins, which become distended and 
tortuous, whilst the arteries, exposed to the continued impulsive force 
from the heart, lose much of their elasticity, and become more rigid tubes, 
causing the peculiar hardness of the senile pulse. The nutrition of the 
textures generally fails in activity, not in degree only, but in kind also, 
chemical transformations and deposits beginning to show themselves in 
the different structures. Thus fibrous and muscular tissues exhibit par- 
tial conversion into fatty matter, and osseous or petrifactive changes en- 
croach on many structures of low 7 organization ; exhibiting a tendency 
to degradation to the composition of mere vegetable and mineral matter. 

This altered proportion of the blood-vessels brings with it morbid 
tendencies, the nature of which will depend much on the great moving 
powder, the heart; now more than ever the prime agent in the circulation. 



SEX. 



35 



If the heart be moderately strong, a fair balance may long be sustained; 
although hemorrhoids, varicose veins, and such irregularities from local 
obstructions, may occur. If the heart be too strong, (which is often the 
case after a life of much muscular exertion,) the small arteries may 
suffer from the unsoftened force of its pulses, particularly in the brain, 
and there is a liability to apoplexy or palsy: and in mucous membranes, 
there is a disposition to active fluxes; hence catarrh, asthma, and affec- 
tions of the urinary organs. The more vascular textures, especially of 
internal organs, are over nourished, and increase in size or weight. If 
the heart be weak or diseased, there will be imperfect circulation and 
tendency to venous congestions, dropsical effusions, imperfect and 
disordered secretions, altered nutrition, and a general failure of all the 
functions, which depend on a sufficient supply of arterial blood : hence 
may arise diseases of the liver, stomach, kidneys, lungs, and in fact of 
any of the viscera : in extreme cases, the lower extremities actually die 
for w T ant of circulation. 

If, instead of the organs of circulation, w r e w T ere to take the alimentary, 
the respiratory, or the urinary apparatus, we should here too find changes 
induced by age, which show the necessarily limited time that man's 
organization is intended to last. Old age is thus attended with increas- 
ing infirmities and liabilities to disease (§§ 16, 18). The very strength 
and activity wmich some functions retain, may, from their partiality, en- 
danger life ; and their gradual and more equal failure degrades the phy- 
sical and often the mental frame of man to a lower scale of existence, 
until he sinks into second childhood, dotage, and imbecility. 

49. VIII. Sex. — The liability which sex gives to the diseases of the 
respective generative organs, is too much of a truism to need mention. 
But the peculiarities of sex are not confined to these organs : they extend 
to many of the structures and functions of the body. 

The male sex is remarkable for the higher development of the muscu- 
lar and voluntary excito-motory system, with a corresponding strength of 
frame ; — for the stronger impulses of the animal passions ; and for a 
greater endowment of the reasoning faculty. These respectively bring 
with them a liability to suffer from diseases of the muscles, limbs, joints, 
heart and great vessels ; — from the evils contingent on undue indulgence 
of passion or appetite ; and from disorders of the brain and its intellectual 
functions. 

In the female sex, the predominant bodily functions are the nutritive, 
the sensitive, and the involuntary excito-motory; whilst the perceptive 
and instinctive faculties and moral emotions preponderate in the mind. 
Hence the greater proneness of females to changes in flesh and blood; 
to disordered sensation, spasms, convulsive and other affections of the 
spinal system ; and to the direct and indirect consequences of the indulg- 
ence or thwarting of instinctive and moral feelings. The predisposing in- 
fluences of the menstrual function have been before noticed (§ 45); it 
may be now added, that its cessation favors the development of various 
diseases of function and structure, especially growths, simple and malig- 
nant. 



36 



EXCITING CAUSES OF DISEASE. 



50. IX. Occupation comprises many circumstances already noticed 
under the heads of predisposing influences. Thus sedentary occupa- 
tions include want of exercise (§ 24), and sometimes impure air (§ 22) ; 
laborious employments operate as excessive exertion (§ 23); other occu- 
pations may predispose to disease by the continued exposure to heat 
(§ 25) or cold (§ 26) which they occasion. Some employments require 
constrained postures, which, if insufficient to induce, may yet promote 
the occurrence of disease ; thus engravers and watchmakers are liable to 
affections of the head from holding the head low; shoemakers and tailors 
are subject to disorders of the stomach from their stooping forward at 
their work. In many other instances, occupations induce disease rather by 
exposing the individuals to the exciting causes, than by inducing a predis- 
position; but, as before remarked, the very circumstances which, in great 
intensity, suffice to excite disease, in a lower degree may only induce a 
disposition to derangement. Thus the slow introduction of lead into the 
system, occurring in the occupations of painting, plumbing, card-enamel- 
ling, and printing, may not cause colic until cold or irregularity of diet 
becomes an additional or exciting cause. The same remark will apply 
to dry grinding, needle-pointing, leather-dressing, and other unhealthy 
occupations. An important element in the influence which employments 
have in causing disease, is the time during which they are pursued ; thus 
an occupation, not in itself unhealthy, may become so when continued 
too many hours in the day; and a work which is attended with risk, may 
be often safely undertaken for short periods with a due amount of relaxa- 
tion or diversion to another pursuit. By attention to this point, the in- 
jurious influences of occupations may be much lessened. 



SECTION III. 

EXCITING CAUSES OF DISEASE. 

51. We now pass to the consideration of exciting or occasional causes 
of disease, or those circumstances and agents which, operating on the 
body, especially when predisposed (§ 14), may excite disease in it. It 
has been stated before (§§ 11, 15), that certain powerful agents, such as 
irritants or poisons, pretty surely cause disease, independently of con- 
stitution or predisposition ; but constitution or predisposition may much 
modify the character of this disease in different cases ; and where the 
agents are less powerful, as in the case of common causes of disease, 
the effects will depend still more on the predisposition, and may be null 
where this is not strong (§§ 15, 19). 

Exciting causes may be divided into cognizable and non-cognizable 
agents. The former class comprehend physical and mental agents, of whose 
existence we can take cognizance, independently of their operation in 
producing disease ; thus cold we know by its effect on our instruments 
and sensations ; muscular exertion, by our witnessing or performing it ; 
and mental emotion, by our consciousness of it. The non- cognizable 
causes, on the other hand, elude our senses, and we infer their existence 



COGNIZABLE AGENTS. 



37 



only from their morbific effects: thus malaria and infection we know by 
no other property than that in question. The subjoined table includes 
both classes. 



Exciting- Causes 
of 

Disease. 



Cognizable 
Agents. 



Non-cognizable 
Agents. 



1. Mechanical. 

2. Chemical. 

3. Ingesta. 

1 4. Bodily exertion. 

5. Mental emotion. 

6. Excessive evacuation. 

7. Suppressed or defective evacuation. 

8. Defective cleanliness, ventilation and 
drainage. 

9. Temperature and changes. 

1. Endemic } 

2. Epidemic > Poisons. 

3. Infectious S 



I. Cognizable Agents. 

52 (1). Mechanical causes, which injure structure, or impede or derange 
Junction. — Besides the obvious instances of tearing, cutting, pinching, 
striking, and straining, which produce at once diseases which fall under 
the province of the surgeon, the physician finds many mechanical causes 
of diseases which he has to treat. Long-continued pressure of articles 
of clothing may produce disease. Tight neckcloths may cause head- 
ache or even apoplexy, by impeding the flow of blood from the Jiead. 
Tight stays may cause fainting, by pressure on the heart and great ves- 
sels; or colic and costiveness, by obstructing the free passage through 
the great intestines. Pressure on the epigastrium, by sitting at a desk 
after a meal, may cause indigestion. Long continuance in one position, 
whether standing, sitting, or lying, will partially obstruct circulation and 
innervation, and produce swelling and paralysis of the lower parts, or 
of those beyond the seat of pressure, and in time may cause inflamma- 
tion and death of the parts pressed upon. Mechanical causes also operate 
within the body. A stone in the bladder irritates by its mechanical pro- 
perties, especially if it be of an irregular shape ; or it mechanically stops 
the flow of urine : so also may a gall stone that of the bile. The intes- 
tinal canal is sometimes mechanically stopped by hardened feces, and 
irritation and inflammation may ensue. The stomach is often irritated 
by the mechanical qualities, bulk, hardness or asperities of its contents: 
thence may ensue vomiting, indigestion, or inflammation of the organ. 
The air-passages of needle-pointers, stone-masons, &c, are irritated and 
inflamed, and at length altered in structure, in consequence of the me- 
chanical action of particles of stone or other substances, which these 
men are continually inhaling in the course of their employment. 

Such instances are endless ; and the further effects of disease are also 
in great measure mechanical. For example: the influence of tumors, 
of diseases of the heart and vessels, the lungs and air-passages, intes- 
tines, and urinary apparatus, injuries and diseases of the bones and 
ligaments, &c. &c, is in great part mechanical, interfering with the 
natural mechanism. 



38 



EXCITING CAUSES OF DISEASE. 



Besides their simple mechanical effects on structures and functions, 
some mechanical injuries, when extensive, directly depress the vital 
powers ; thus, concussion of the brain, crushing or tearing off a limb, or 
a blow on the epigastrium, causes fainting and extreme weakness of the 
heart's action, and may thus cause death. Slighter mechanical injuries 
are causes of irritation or excitement, which may be local or general, 
according to the excitability and extent of the part irritated. 

53 (2). Chemical causes of disease are even more varied than mechanical, 
because chemical agents are more numerous. "We are acquainted less 
with the chemistry than with the mechanism of the animal body, and 
therefore can less distinguish causes which act by chemical properties 
from those w T hich have complex relations to vital properties. But we 
recognize chemical irritants in acids, alkalies, and many salts, whether 
applied to a part, or inhaled in form of gas or vapor. So what are called 
chemical poisons, such as corrosive sublimate and other metallic salts, 
the strong acids and alkalies, iodine, chlorine, &c, produce disease by 
their known powerful chemical affinities, which tend to decompose tissues 
and disorder functions. 

We cannot doubt that many of the matters which cause disease in the 
alimentary canal, do so by virtue of their chemical qualities. The pro- 
cess of digestion, although always in part chemical, is so under the 
superintendent influence of a superior vital power: no sooner does this 
power fail, or the chemical agencies or decompositions become too strong 
for it, than we have fermentation and putrefaction, which cause eructation 
of gas or sour liquid from the mouth, and there may follow the discharge 
of ill-colored and unusually fetid matter by stool ; then, too, may arise a 
number of disorders, which may in great part be referred to the influence 
of these injurious chemical processes. 

There appear to be at least four modes in which chemical agents may 
excite disease in the body : 

1. As local irritants, as the diluted acids, alkalies, and various salts, 
the chemical operation of which is resisted by increased action excited 
in the part (§ 16). [The carious maxilla? of the workmen exposed to 
the vapors of phosphorus, would appear to be due to this cause. — C] 

2. As corrosives, as in the case of strong acids, alkalies, some metallic 
salts, chlorine, and iodine, which by their powerful chemical affinity, so 
completely overcome the vital affinities of textures as to decompose them, 
and thus to kill and alter the condition of the part. 

3. As septics, promoting the spontaneous decomposition of the fluids 
or solids of the body, in the same way that ferments or putrescent mat- 
ters operate on dead organic matter. 

4. As chemical alteratives, modifying the changes which take place 
in digestion, assimilation, transformation of textures, secretions, &c, as 
in counteracting acidity by alkalies, in variously influencing the state 
of the blood and urine by acids, alkalies, &c. ; and in causing the pro- 
duction of hippuric acid in that excretion, by the administration of ben- 
zoic acid. (Ure.) 

The operation of chemical agents on the whole body will vary ac- 
cording to their intensity and extent. Irritants, if extensively applied, 
cause feverish excitement. Corrosives, if acting widely, depress the 



INTOXICATING LIQUORS. 



39 



vital powers, like the shock of violent mechanical injuries (§ 52) ; if 
partially, the vital powers are excited to resist them, and they operate 
as irritants. Septics, if very powerful, may speedily overwhelm the 
preserving vital powers of the body, which then speedily passes into a 
state of corruption, as in the case of extensive gangrene, pestilential 
diseases, &c. : but if the septic matter be scanty, and the vital powers 
strong, they are excited to increased action, and by means of accelerated 
circulation, and augmented excretions, the body may get rid of the offen- 
sive matter (§ 17). Such struggles are instanced in typhoid fevers, 
epidemic cholera, dysentery, &c. 

54 (3). The solid and liquid ingesta are a fertile source of disease, and 
in various ways. Their mechanical and chemical properties have al- 
ready been noticed (§§ 52,53). But further, the ingesta may cause 
disease — 

a. By non-alimentary matters acting injuriously. 

b. By aliment defective, or ill proportioned in quality. 

c. By aliment defective, or excessive in quantity. 

55 (a). Of the n on- alimentary matters contained in the ingesta, salt, 
spices, pickles, and other condiments, and spirituous or fermented liquors, 
are frequent exciting causes of disease. They are all more or less 
irritating or stimulating to the digestive apparatus; and if used indis- 
creetly, may induce inflammations, congestions, and functional disorders 
of these organs, and, in some instances, irritation of other parts, and of 
the whole system. Salt in excess irritates the stomach, retards diges- 
tion, and causes feverishness with thirst. Much of these effects is due 
to the affinity of the salt for the water of the animal fluids, and may be 
induced by other saline matters beside common salt. Wherever excess 
of salt is contained in the body, there will be exosmosis and endosmosis 
of the water from the adjoining vessels and tissues, until the salt is equally 
distributed among them, and before this is accomplished, there will be 
such a diminution of the fluids within the blood corpuscles, and on the 
surface of membranes, as may readily account for the thirst and disturb- 
ance caused in the system. According to Liebig, salt impedes the 
deposition of fat. Animals will not fatten on salt food ; — a hint for the 
corpulent. 

56. But the operation of intoxicating liquors is more extended: being 
soon absorbed, their stimulant action is speedily exercised on distant 
parts, especially on the vascular and nervous system. Being absorbed 
by the veins, they pass by the portal vein into the liver, the function and 
structure of which are particularly apt to suffer from excesses, especially 
when spirits have been freely indulged in. So, too, the kidneys, which 
are the natural emunctories through which such extraneous matters are 
eliminated from the system, are often over-stimulated, and are injured 
in their secreting power, and ultimately in their structure also. The 
heart and vessels are over-excited at first, and afterwards lose their 
tone; and the processes of digestion and nutrition become impaired and 
modified. The nervous system is an especial subject of the disordering 
influence of 1 intoxicating liquors. A large quantity taken at a time is a 
narcotic poison, inducing a short period of cerebral excitement or intoxi- 
cation, followed by insensibility, in which the functions of the brain 



40 



EXCITING CAUSES OF DISEASE. 



are more or less completely impaired, and in extreme cases those of the 
spinal marrow suffer; and if the influence be insufficient to stop respi- 
ration, yet it may be imperfectly performed, and congestions are formed 
in the brain and other organs. Hence apoplexy, palsy, phrenitis, or 
delirium tremens, may follow, and the whole frame may suffer from the 
effects of the poison. Even when less excessive quantities are taken, 
and their first effect is mere intoxication, the headache, sickness, and 
inappetency, and the feelings of wretchedness and depression which often 
ensue, sufficiently prove that disorder has been produced, and that such 
artificial excitements cannot be abused with impunity. 

The habitual indulgence in strong drinks causes further varieties of 
disease, which are so prevalent as to deserve notice. When taken only 
or chiefly with food, not as a substitute for it, but as a constituent of 
general "free living," they contribute to the production of an abundance 
of ill assimilated, overheated blood ; which either finds its vent in erup- 
tions on the surface, or in local hemorrhages or fluxes, or causes various 
functional disorders, such as palpitation, vertigo, stupor, dyspepsia, bilious 
attacks, &c. ; or may tend to the production of a fit of gout or gravel. 
The latter results are promoted by such beverages as contain much free 
acid as well as an abundance of spirit, such as port wine, rum punch, 
and hard strong beer. The less acid malt liquors, ale and porter, tend 
rather to induce liver disorders, and an abundant deposition of fat in the 
body. All these consequences will be much favored by sedentary habits 
(§ 24) and deficient excretions: active exercise carries off much of the 
spirit and superfluous aliment by an increased elimination of the acids 
of respiration and perspiration. 

The most disastrous consequences of intemperance are exhibited by 
the habitual drunkard, who, in proportion as he indulges in liquor, loses 
his appetite for food, and his power of digesting it. He then drinks 
and starves, and the disease which ensues comprises the exhaustion of 
inanition with the more direct effects of the alcoholic poison. Thus in 
delirium tremens, the drunkard's disease, together with the permanent 
restless excitement of the irritated nervous system, which adds more 
and more to the exhaustion, the weakness of mind and body is fearful, 
and in bad cases affect even the organic functions, so that the pulse is 
very weak and frequent, the excretions scanty and depraved, and the 
respiration is too imperfectly performed by the involuntary powers to 
permit sleep to ensue. This exhaustion must soon terminate in death, 
unless prevented by appropriate treatment; and this must comprise, 
besides opium (the common remedy), ammonia and other stimulants to 
the circulation and respiration ; purgatives and diuretics to free the blood 
from the excrementitious matter that has accumulated in it ; and fluid 
nourishment to repair its waste. Without these adjuncts, opium will 
not only fail to procure sleep, but its narcotic influence may extinguish 
the flame of life. 

Pernicious as fermented liquors are in their abuse, yet these and other 
adjuncts to food, when taken with careful moderation and discrimination, 
often prove beneficial by aiding the digestion where it is weak, and by 
counteracting various exhausting and depressing influences, which are 
frequently arising out of the artificial condition and employments of 



IMPURITIES IN FOOD. 



41 



society, especially in large towns and in cold climates. Total abstinence, 
therefore, is preferable to moderation, only because, it is morally easier 
to practice, not because it is more salutary in its physical effects. 

57. Disease may be excited by unwholesome articles with which the 
food is adulterated. To this class of causes belong various poisons ; 
the operation of some of these will be noticed under the head of modes 
of death (see chapter on Prognosis); but for further details, works on 
toxicology and materia medica must be consulted. There are some 
noxious matters occasionally mixed with food, which gradually produce 
deleterious effects. Thus salted provisions too long used will cause 
scurvy; ergotted corn has been known to produce dry gangrene. Lead, 
gradually introduced, causes constipation, colic, paralysis, and atrophy. 
Impure water, used as a drink, is a common cause of disease: containing 
decaying vegetable or animal matter, it may induce sickness, diarrhoea, 
cholera, and typhoid symptoms: hard w T aters, w T hich are impregnated 
with some of the salts of lime, render the bowels costive, and are sup- 
posed to favor the production of calculous diseases and bronchocele : 
brackish waters, containing saline matter, may induce dyspepsia and 
diarrhoea: chalybeates, containing iron, are constipating; &c. 

Under the head of non-alimentary ingesta which may cause disease, 
we must reckon various medicines; and that not only when injudiciously 
administered, but as commonly prescribed : the remedies necessary to 
cure or relieve many diseases, are not uncommonly necessary evils ; they 
remove one disorder by inducing another, and it is well if the evil thus 
induced is the smaller of the two. 

58 (6). Aliment unfit in quality is another condition of the ingesta 
that may cause disease. Man is by nature and habit an omnivorous 
animal ; and in general his health is best maintained by mixed propor- 
tions and varieties of animal and vegetable food. The insalubrity of the 
simpler constituents of food, when separate, even those supposed to be 
most nutritive, has been well shown by the numerous experiments of 
Majendie, Gmelin, and others. They fed dogs, geese, donkeys, and 
other animals, on articles which are generally considered highly nutritive, 
as sugar, gum, starch, oil, or butter; the animals died with symptoms 
of starvation almost as soon as if they had been kept without food. Even 
bread, when too fine, is insufficient for nutriment. A dog fed on pure 
white bread lived only fifty days, whereas another fed with the coarsest 
brown bread was well nourished, and seemed capable of living to an inde- 
finite period. According to the researches of a commission of the French 
Institute, (the report of which was published in 1841,) animals fed on 
pure fibrin, or albumen, or gelatine, die of starvation with reduced 
quantity and quality of the blood, almost as soon as if not fed at all. 
Gluten, or vegetable albumen, is the only simple principle which will 
alone maintain life, and the nutritious qualities of vegetable food depend 
chiefly on the quantity of this azotized principle which they contain. 
Bread may therefore well be called the staff of life. Even animal albu- 
men and fibrin require mixture with vegetable matter to make them 
properly nutritious as well as wholesome ; and gelatine and oily matters 
are still less available for nourishment without much combination. In 
the experiments just alluded to, animals could be supported on meat or 



42 EXCITING CAUSES OF DISEASE. 

flesh, which comprises several of the elementary matters, although they 
were not sustained by any one of these matters separately. 

The utility of a due combination of organic elements for the food of 
animals has long been ably shown by Dr. Prout, who has pointed to 
Nature's aliment, milk, as the great type of all proper kinds of nourish- 
ment ; as it contains albumen, oil, sugar, and water, so all other kinds 
of food used for ordinary sustenance, ought to include these elements, 
or others isomeric (that is, identical in ultimate composition) with them ; 
and it is quite true that all combinations of food sanctioned by custom, 
do comprise such ingredients. Bread contains two of these, gluten, 
which is vegetable albumen, and starch, which is isomeric with sugar ; 
but bread is not relished without butter or some fat with it. Neither does 
meat, which contains albumen and fat, suit the taste without a combina- 
tion with bread, rice, potatoes, or some vegetable, which represents the 
amylaceous or saccharine principle. 

59. Much discussion has occurred of late as to the share or purpose 
which each of the elements of food serves in the animal economy, and 
the extent to which they can be changed by the process of digestion and 
assimilation. Dumas and the French chemists generally have maintained 
that this process is limited to the separation and appropriation of princi- 
ples ready formed in the food, and does not extend to the conversion of 
one into another. Thus all the albumen or fibrin in the body is derived 
from the albumen or gluten of the food ; and all the fat from fat or oil 
contained in the nourishment. This view, as regards the formation of 
fat, is opposed by many familiar facts, such as the fattening of domestic 
animals with farinaceous and vegetable foods, which contain very little 
fat; and it has been completely negatived by the experiments of Petroz 
and Boussingault, which have proved that geese and pigs, during the 
process of fattening, gain more fat than is contained in their food.* It 
further appears probable that the conversion of sugar into fat is promoted 
by the agency of bile; for H. Meckel found that, by keeping a mixture 
of bile and grape sugar at a warm temperature, the quantity of fat in 
the mixture increased to double in five hours, and more than treble in 
twenty-four hours. It is pretty certain, therefore, that fat may be formed 
from starch or the saccharine principle, and probably from the albumi- 
nous also. But there is no decisive evidence to show that albumen or 
gelatine can be elaborated from fat, starch, or sugar, at least under com- 
mon circumstances ; and it is certain that these elements alone will not 
long sustain animal strength or life.f 

Baron Liebig has advanced a very comprehensive hypothesis with re- 
gard to the purposes of the different proximate elements of food. He 
considers that the albuminous principle alone supplies the material from 
which the textures are nourished, and all the non-nitrogenous elements 

* Dr. Day's Report on Chemistry in Dr. Ranking's Abstract, July 1846, [p. 273. Am. Ed.] 
f In a very able paper on Vital Affinities, just published by Dr. Alison, (Transac. of Royal 
Soc. Edin., 1847,) he adduces many arguments in favor of the inference that albumen may 
be formed in the animal body, especially in vigorous health: and he suggests that the inter- 
vention of ammonia can famish the material from which starch and other non-azotized arti- 
cles of food receive azote, and by the power of the vital affinities are converted into albu- 
men. There is much reason on the side of this notion; it may be seen that I have long 
entertained a similar opinion with regard to the conversion of gelatine into albumen. 



ILL- PROPORTIONED FOOD. 



43 



are converted into carbonic acid and water by the process of respiration 
for the production of animal heat. Although too exclusive to be fully 
admissible, the general outline of this view appears to be consistent with 
facts, and will assist us in studying variations in food as a cause of dis- 
ease. 

60. The chief alimentary matters may be divided into the albuminous, 
the gelatinous, the oleaginous, and the saccharine, or amylaceous ; and 
we shall briefly consider how an excess or defect, and in some instances 
the quality, of each of these may operate in causing disease. 

Albuminous or protein aceous articles, such as the lean of meat, fowl, 
and fish, gluten of bread, and casein of milk, are those which supply 
the albumen and fibrin of the blood and textures of the body. Hence 
deject of this kind of nourishment will cause, first, weakness of the heart 
and other muscles, and at length wasting of these, and of other textures, 
with diminution of the quantity and richness of the blood. Excess of 
carneous food, particularly the richer kind, butcher's meat, tends to cause 
plethora, with an excited circulation and feverishness, which may result 
in hemorrhage, inflammation, gout, lithiasis, &c. 

Bad quality of albuminous food is peculiarly injurious to persons of 
weak digestive and assimilative powers: thus the casein of cheese, the 
fibrin of stale or salted meats, and the gluten of sour or ill-baked bread 
or heavy pastry, instead of forming good protein, is apt to degenerate 
into the products of animal decay, lithic and lactic acids, urea, &c. 
Hence may arise gout, rheumatism, calculous disorders, &c* 

Gelatinous foods, soups, broths, isinglass, jellies, &c, are by no means 
so supporting as albuminous matters; but when combined with bread, 
they nourish the body so well that it seems very probable that, in a healthy 
constitution, gelatine may assist in the formation of albumen; but when 
used in excess, or to the exclusion of bread and meat, it ceases to be 
nutritious, and the strength and flesh will waste. 

Oleaginous or fat nutriment, butter, fat of meat, oils, and seeds con- 
taining them, not only supplies the material for the adipose textures of the 
body, but it assists in the formation of other structures and secretions, 
(oil globules forming a normal constituent of them,) and it affords the 
strongest fuel for the maintenance of animal heat by respiration. From 
what has been before stated (§ 59), it may be inferred that fat may also 
be formed from saccharine and starchy food, as well as. from the store- 
houses of the adipose membrane: but defect of fat in the food has been 
observed to induce the following morbid results: loss of flesh, especially 
of the rounded plumpness and smoothness of the surface, which becomes 
skinny, wrinkled, and often dry and scurfy; deficient secretion of mucus 
at the orifices of mucous passages, and of synovia in the sheaths and 
joints ; insufficient formation of bile, and consequent imperfect digestion 
and feculent excretion, with diminution of animal heat. Excess of fat 

* In this statement I disregard the dogma of Liebig that the materials of food serve for 
respiration and nutrition only, and that urea, lithic acid and excrementitious matters are de- 
rived from the decay of the tissues alone. Daily observation convinces the medical practitioner 
that in persons of weak assimilation, certain articles of food, as specified above, so certainly 
and promptly cause an increase of animal matter in the urine, that there can be no doubt 
that they are the direct sources of it. 



44 



EXCITING CAUSES OF DISEASE. 



food may disorder the stomach, by its indigestibility, becoming rancid, 
and causing heart-burn or sickness, and sometimes a bilious taste; for 
much fat seems to induce a regurgitation of bile into the stomach, which 
is supposed to assist in its digestion (Beaumont) and absorption (Matteucci). 
If the fat is carried into the blood, it may cause inconvenient obesity by 
its accumulation in the adipose texture of various parts of the body; or 
if the subject be naturally lean, and incapable of accumulating fat, the 
superfluity must be carried off, and the natural emunctories, the seba- 
ceous follicles of the skin, and the liver, may be disordered; hence acne 
and other follicular diseases of the skin, and various bilious disorders, 
will ensue. These results will be more readily produced in sedentary 
persons, in whom the exercise of the lungs is insufficient to consume the 
superfluous fat. On the contrary, those who use active exercise can 
often take considerable quantities of fat with impunity, and sometimes 
with advantage. For similar reasons, oily food is better borne in cold 
than in hot climates and seasons; thus, as Liebig has pointed out, the 
Laplander relishes train oil, which serves to sustain the warmth of his 
body; whilst the Italian, in a sunny climate, prefers the less combustible 
food, maccaroni and fruit, which nourish without heating. 

The quality of oily matter in the food is materially concerned in its 
morbific effects, those most prone to chemical change or to become solid, 
being more likely to disagree than others. Thus, stale or tainted butter 
or fats, and rancid oils, are peculiarly offensive to the digestive organs, 
both from the production of injurious acids (butyric and oleic), and from 
their spissitude rendering them incapable of the minute division neces- 
sary for their absorption and appropriation to the nutritive process. On 
the other hand, fresh butter, mild fat, and sweet salad oil, agree well and 
nourish, especially when intimately blended with farinaceous or succulent 
vegetable matters; and the codliver oil, when freed from its impurities, 
is often borne by the weakest stomachs. 

Amylaceous or starchy foods, such as arrowroot, sago, tapioca, and 
many kindred preparations of farinaceous articles, although isomeric (i. e. 
consisting of the same elements) with saccharine matter, are not quite 
similar in their physiological effects. Like it, they probably sustain the 
body rather by supplying a material for the process of respiration, than 
by nourishing the textures; they thus save them from the consuming 
influence of the oxygen absorbed through the lungs; and if taken in 
excess, they may either lead to the formation of fat (§ 59), which is de- 
posited in the textures, or passing into fermentation, they may give origin 
to acetic, lactic, and oxalic acids, and other matters of an injurious tend- 
ency; and this latter effect occurs more from saccharine than from 
amylaceous food. On the alimentary canal, too, their effects in some 
degree differ, amylaceous food in excess impairing the action of the in- 
testines, and the secretion of the liver, whereas sweet things often relax 
the bowels and cause a redundancy of bile. These different effects of 
saccharine matter are probably connected with its either often containing 
or readily forming vegetable acids, which irritate the alimentary canal, 
and which may become causes of dyspepsia, diarrhoea, diabetes, rheu- 
matism, oxaluria, and other disorders of the same class. 

Amylaceous and saccharine matters, forming the mildest materials of 



QUANTITY OF FOOD. 



45 



food, serve to dilute the stronger articles, fibrin and oil, and to render 
them both more palatable and more digestible; when, therefore, the for- 
mer are deficient, the latter are more apt to disagree, and fail to impart 
their nutrient properties. These and other vegetable principles, such as 
gum, vegetable jelly, extractive, &c, also contain an alkali combined 
with vegetable acids which are decomposable in persons of strong diges- 
tion, and this alkali becomes useful in counteracting the acidity which 
results from the processes of transformation continually proceeding in the 
body. Thus fruits and other vegetables assist in neutralizing and elimi- 
nating lithic acid, and in preventing the occurrence of gout and gravel. 
This statement is in accordance with the views of Prout, Liebig, and 
Wohler; but I have restricted its application to the case of persons whose 
digestion is strong ; for in those of feebler powers, I find commonly that 
vegetable acids and fruit increase the acidity of the urine, and are there- 
fore injurious: whether by passing unaltered through the circulation, or 
by irritating the primse vise, and thus leading to an unusual development 
of hydrochloric and other unchangeable acids, I cannot say, but the latter 
would appear most probable. 

61. Thus the selection and combination of articles proper for food 
would be a difficult task, requiring much scientific knowledge and cal- 
culation, were it not that Nature has supplied us w T ith an instructive 
guide, which happily adapts itself to the varied wants of the system in 
change of season and other circumstances. The appetite and taste ge- 
nerally instruct us pretty safely as to the best proportions of different 
kinds of food ; but they must not be perverted and pampered by condi- 
ments, and refined modes of cooking. These are expedients to coax and 
deceive the appetite and taste ; and if these guardians of the nutritive 
department are cheated, it is no wonder that the department becomes 
deranged. 

62 (c). Aliment may be excessive or deficient in quantity. Sometimes 
the appetite is inordinate; more frequently it is pampered; in either 
case, if gratified, more food is taken than the expenditure of the system 
requires. If the digestive organs fail in appropriating the nourishment, 
they become distended, irritated, and otherwise disordered by what they 
cannot digest. If they are strong, and digest the excess, they send too 
much chyle into the blood, over distend the vessels, and derange the 
function of assimilation; hence may result plethora, apoplexy, gout ? 
gravel, or some congestive hemorrhage, or inflammatory disorder, to 
which the individual is predisposed (§ 14). Such evil consequences of 
repletion will ensue the more readily in sedentary persons, in whom the 
w r aste of the body is little, and the excretions scanty. 

63. Defective nourishment may excite various disorders. In the ex- 
treme case of privation of food, the cravings of hunger are alternated 
with nausea and a sense of sinking: then follow extreme depression 
alternated with transient fever, delirium, and general disorder both of 
body and mind, with increasing feebleness, and inability to maintain 
animal heat. It is a curious fact, that, in this state, the stomach becomes 
inflamed ; probably from the irritating action of its secretion on its un- 
relieved vessels. Even in less degrees of abstinence, enjoined in the 
treatment of disease, symptoms of vascular and nervous irritation often 



46 



EXCITING CAUSES OF DISEASE. 



arise in the midst of general weakness. By many practitioners of the 
Broussaian school, these symptoms are erroneously taken as indications 
for an increase of the antiphlogistic plan, when a judicious return to 
nourishing food will really prove the best cure. Deficiency of food, if 
long continued, causes general weakness of the functions, and wasting 
of all the textures, except those of the nervous system. The blood be- 
comes thin and easily extravasated ; the gums spongy and bleeding; fat 
disappears; muscles become thin and flabby; the legs cedematous; diar- 
rhoea often occurs; ulcers appear in the cornea and other parts which 
are least vascular; a state of scurvy or cachexy is induced, from which, 
if advanced, an improved diet may now fail to restore. Chossat found 
that, in animals gradually starved to death, the temperature progressively 
declined, and unless maintained artificially, the animals seemed to die of 
cold. All the textures, even that of the bones, sustained great loss of 
weight ; but those of the nervous centres far less than any others. This 
fact I would explain by the peculiar condition of the blood-vessels sup- 
plying these centres, which enables them to monopolize the little blood 
remaining; and thus w T e gain a further interpretation of the predominance 
of nervous symptoms in persons suffering from inanition. (See Ansemia.) 
In less extreme cases, poor living may excite scrofulous and tuberculous 
disease, and other kindred forms of degeneration of organs. The bad 
influence of poor living is much more felt in those who are confined in 
close habitations, as in prisons, poor-houses, the cabins of ships, and 
besieged towns, than in those who are at large (§ 22): and it is under 
such circumstances, that the insalubrity of some kinds of food, however 
nutritious, becomes apparent. Thus, even bread with meat or broth will 
not preclude the occurrence of scurvy ; but a sufficient addition of fresh 
vegetables, and even of potatoes, prevents this disease from appearing. 
—(Dr. Baly, Med. Gazette, Feb., 1843.)— [Chomel observes, "The pro- 
longed use of a scanty regimen is a frequent cause of obstinate consti- 
pation and various digestive troubles, in those who fast throughout Lent," 
a fact annually verified in the writer's practice. — C] 

64 (4). Excessive bodily exertion of various kinds is a common ex- 
citing cause of disease. General muscular efforts, as in running, walk- 
ing up hill, rowing, &c, hurry the movement of the blood back to the 
heart, and resist its distribution through the arteries in such a degree 
that the heart, the lungs, the brain, and other organs, have an unusual 
pressure of blood upon them (§ 51). 

The heart excited to inordinate action, is often strained and distended, 
and its function, or even its structure, and that of the great vessels, may 
be impaired in consequence. This is especially apt to happen if there 
be anything already imperfect in the structure of the organ, its valves or 
vessels; and there are naturally very various degrees of perfection and 
strength in these parts. 

The brain is particularly liable to suffer from violent exertion, espe- 
cially if joined with a stooping or constrained posture; for its vessels are 
not, like those of the limbs and trunk, supported by muscular pressure 
upon them, and the excited heart can therefore send its blood into them 
with more force. Hence giddiness, noise in the ears, deafness, defect- 



BODILY EXERTION. 



47 



ive Vision, convulsions, palsy, and apoplexy, have been brought on by 
violent exertion. 

The lungs are also apt to suffer; for the blood being returned to them 
faster than they can arterialize it, they become greatly congested ; hence 
cough, dyspnoea, haemoptysis, or inflammation of the lungs, may ensue; 
and the texture of the lungs may also sustain injury in consequence of 
the violent strain to which it is subjected by the increased exertions for 
breath. 

Other internal organs sometimes are disordered by the blood thrown 
or retained in their vessels by the pressure of external muscular action. 
Derangement of the liver, hsematemesis, haemorrhoids, and haematuria, 
have been brought on by such a cause. The sharp pains or stitches felt 
in the sides or abdomen, on running fast, are commonly supposed to be 
in the liver or spleen: but more probably they are spasms of the intes- 
tines — temporary colic, produced by irregular pressure on them, when 
their sensibility is raised by the blood unduly thrown into them. 

Some kinds of muscular exertion peculiarly affect certain organs. 
Thus loud reading or speaking, or blowing wind instruments, especially 
tries the organs of respiration and the voice, and may cause hemorrhage, 
inflammation, and various diseases of these organs. Excessive or rough 
riding or leaping may injuriously affect the kidneys and organs of gene- 
ration. Straining to lift a heavy weight, or at stool, or in any continued 
effort, which implies holding the breath, endangers the structure of the 
vessels of the chest and brain, on which there is no equally counteract- 
ing muscular pressure. 

Bodily exertion, long continued, may also cause disease by its exhaust- 
ing effects. In extreme degrees, this exhaustion may amount to syncope, 
and even death: short of this, it may cause great weakness of muscles 
and of the heart, with corresponding depression of other functions, with 
congestion of the viscera, defective assimilation and excretion : hence 
arises the low typhoid or adynamic fever which sometimes follows pro- 
longed fatigue. In slighter cases, we have giddfness, faintness, nausea, 
loss of appetite, indigestion, costiveness, amenorrhcea, and other varieties 
of injured function. When exercise is carried on so long, or to such a 
degree, as to impair the organic functions, it thereby induces disorder in 
them in addition to the weakness, prostration, and actual suffering in 
the animal functions. A serious part of such disturbance is the sleep- 
lessness which ensues from extreme fatigue, and which may bring the 
patient into a state resembling that of delirium tremens. This, as we 
have already mentioned under the head of predisposing causes (§ 23), is 
mainly due to the state of the respiration, wdiich, being insufficiently 
maintained by the weakened spinal function, is aided by continued vo- 
luntary efforts, which are manifest in the frequent sighing that takes 
place. In this case, the best hypnotic will be found in a diffusible stimu- 
lant. 

65. The opposite extreme, want of exercise, is capable of exciting as 
w T ell as of predisposing to disease (§ 24). Thus internal congestions, 
deficient and disordered secretions, general plethora, over nourishment 
of adipose texture, and wasting of muscles, and various evil consequences 
of these morbid conditions, may result from this cause when long in ope- 



48 



EXCITING CAUSES OF DISEASE. 



ration. When combined with some of the other disturbing influences 
noticed in this section, it is a still more ready and common cause of 
mischief. Some organs more particularly suffer from a sedentary mode 
of life ; for example, the liver, from the increased task of decarbonization 
of the blood which deficient respiratory exercise throws on it; the brain, 
from its vicinity to the centre of the circulation, exposing it to an accu- 
mulation of blood when the distant circulation fails ; hence bilious dis- 
orders, dyspepsia, haemorrhoids, headache, giddiness, &c. 

66 (5). Strong menial emotion, or acute sensation, is a common cause 
of disease. Closely knit together as the mind and body are, it is not 
surprising that they should ever be ready to affect each other, and that 
when the impression is strong, the affection should not be slight or transient. 
The heart most remarkably suffers from such causes. Thus a sudden 
shock, whether of grief, surprise, fear, or even joy, may cause fainting, 
partial suspension of the action of the heart; nay, even death has ensued; 
and the expressions "frightened to death," and "killed with joy," are 
not always mere figures of speech. Sudden acute pain often causes 
fainting. Palpitation and irregular action of the heart are very common 
effects of emotions. 

Other parts also suffer from strong moral impressions. Spasmodic 
asthma and spasmodic affections of the throat are sometimes thus induced. 
Apoplexy, palsy, inflammation of the brain, epilepsy, and insanity, have 
been caused by excessive anger, terror, surprise, and joy. 

Very commonly, mental emotions affect the secreting organs, and es- 
pecially the functions of the alimentary canal. A piece of very bad 
news takes away appetite, or impairs digestion. Fright or anxiety often 
loosens the bowels, or brings on a bilious attack, or jaundice. The 
uterine periodic function is remarkably subject to the influence of moral 
emotions, and many of its disorders may often be traced to this source. 

The slower emotions of the mind and over-exertion of its faculties are 
also exciting causes of disease. Long-continued depression or anxiety 
sometimes induces dyspepsia, costiveness, or diarrhoea, asthma, and 
functional disorders of the heart, menorrhagia, and dysmenorrhcea ; and 
in time, structural diseases of the same parts occasionally follow these 
functional affections. Over-exertion of the faculties, or excitement of 
the passions of the mind, is chiefly felt in its own functions, or in its own 
organ, the nervous system. Hence may arise congestions of the brain 
and exhaustion of nervous power, with giddiness, stupor, headache, dull 
and disordered sensation, and even apoplexy and palsy. Or the disease 
may be inflammatory, with symptoms of irregular excitement, nervous- 
ness, delirium, tremor, convulsion, partial paralysis, &c. Sometimes the 
effects of excessive mental exertion or moral emotion are apparent only 
in the phenomena of the mind, the powers of which are injured or dis- 
ordered, and various forms of insanity are produced. When we consider 
the variety and amount of food and condiment, employment and excite- 
ment, that pass into the minds of persons in the busy and worrying scene 
of civilized life, it is not extraordinary that the mind, as well as the 
digestion, or other function, should occasionally be disordered by such 
causes. 



EXCESSIVE EVACUATION. 



49 



67 (6). Excessive evacuation or loss either of blood or of some secretion, 
was formerly noticed (§ 28) as a cause of debility, which predisposes to 
other diseases; but if the loss be great or sudden, it may produce imme- 
diate disease. A certain fulness of the heart and blood-vessels is required 
for their healthy functions, as well as for those of all the organs which 
they supply. If a moderate quantity of blood be suddenly withdrawn, 
or a large quantity less suddenly, the heart's action will be impaired, 
rendered irregular, and maybe interrupted, and the brain not receiving a 
current sufficient to maintain its functions, there may be fainting, with 
loss of consciousness, accompanied or followed by disordered function, 
palpitation, delirium, convulsion, or by death. The sudden impression 
in these cases is evidenced more on the brain than on the heart; for these 
effects may be induced by the loss of a much smaller quantity of blood 
in an erect or sitting posture than in a horizontal posture. Similar results 
have been found to ensue from the sudden removal of pressure from the ves- 
sels in any considerable part of the body, as by the discharge of the fluid 
of ascites, or by enclosing a limb in an exhausting tube. (Dr. Arnott.) 
Lower mentions a case of extensive varix (enlargement) of the veins of the 
lower extremities, in which the patient could not stand without fainting, 
until the legs were bandaged. In these cases, much of the blood, although 
not removed from the system, gravitates into vessels, where it becomes 
unavailable for the general circulation. The fainting which occurs in 
these cases is called cerebral syncope, because the functions of the brain 
are suspended, consciousness is lost before the heart's action is interrupted ; 
but the disorder of the brain reacts on the heart, and adds another in- 
fluence to impair its action also. This is Dr. Alison's explanation. On 
the other hand, if the hemorrhage is gradual, and the posture horizontal, 
other functions fail before the consciousness is lost — the chief symptoms 
being " feebleness of muscular action; paleness and collapse of the coun- 
tenance; coldness, beginning at the extremities; cold sweat, beginning 
on the face; the pulse imperceptible," and the heart's action becoming 
so. The true nature of these effects, and the reaction and nervous symp- 
toms with which they are often followed, will be considered hereafter in 
connection with the subject of anaemia. 

Not only blood-letting, but other evacuations, purging, sweating, and 
vomiting, the catamenial and seminal* discharges in excess, are capa- 
ble of producing syncope and general debility. The depression and 
faintness induced by these, although less prompt, are often more perma- 
nent than those from blood-letting ; for such evacuations imply, not only 
reduction in the mass of blood, but also an exhaustion of the vital ener- 
gies in the secretions and functions concerned in producing them. 

The diseases gradually induced by these several causes of evacuation, 
are seldom of a simple kind. General weakness of the muscles and 
functions is commonly a result; but this is often complicated by symp- 

* [A man who, during his whole life, has exposed himself with impunity to the incle- » 
mencies of weather, is attacked with rheumatism, when exposed after excessive venereal 
indulgence. Under similar circumstances, the same disposition to attacks of yellow fever 
was noticed at St. Domingo; and Diemerbroeck remarked at Nymegen, that all who mar- 
ried during the continuance of* the plague, were attacked with the disease soon after- 
wards. (Chomel.) — C] 

4 



50 



EXCITING CAUSES OF DISEASE. 



toms of partial reaction, palpitation, spasms, noises in the head, images 
in the sight, pains in different parts, sometimes very acute, but seldom 
long fixed, partial paralysis, and a defective and disordered state of the 
excretions. 

68 (7). Deficient evacuation of excrementitious matter, whether na- 
tural or accidental, is a very fertile source of disease. The operation of 
this class is somewhat diversified, some causing disease by the positively 
noxious influence of matter retained in the system, which is the case of 
the excretions of urine and feces ; others, by causing fullness of the ves- 
sels, and the various disorders which this may induce. To the latter 
cases belong sudden suppression of hemorrhages, or other discharges 
which have become habitual. 

The matter of alvine and renal excretions is essentially pernicious, 
and cannot be long retained even in their natural repositories without 
causing mischief. Feculent matter, when it has reached the large in- 
testine, is still acted on by the absorbents, which take up its more fluid 
parts, and with them, if long retained, fetid matter, which ought to be 
excreted. The solid residue becomes hard and scybalous, and may re- 
main lodged in the cells of the colon, a cause of irritation, distention, 
and obstruction (§ 51). Sometimes the system suffers before the intes- 
tine itself; at length, however, or sometimes at first, this part becomes 
irritated ; colic, diarrhoea and inflammation may ensue — nay, in some 
instances, where efficient remedies are neglected, even ulceration and 
other structural changes take place, before the offending matter is dis- 
lodged. 

The retention of urine has even more serious effects. Besides me- 
chanical distention, irritation and rupture, which may follow from the 
constantly accumulating secretion (§ 51), the fluid is partially reab- 
sorbed, giving a urinous smell to the breath and perspiration, and some- 
times causing typhoid symptoms, which in extreme cases prove fatal, 
with delirium or convulsions, and coma; and effusions of serum, con- 
taining urea, are found in the brain, chest, and other parts. These are 
effects more commonly of suppression than of mere retention ; but, in 
fact, suppression often follows retention : the retained urine is prone to 
decomposition (§ 53); highly irritating and offensive matters are pro- 
duced, which cause injury to the bladder, rapidly extending up the ure- 
ters to the kidneys, whose function then becomes impaired or suppressed. 
In several cases of the early stage of the severest form of Bright's dis- 
ease, in which the urine was very scantily secreted and highly albumi- 
nous, I have seen typhoid symptoms of the worst character ensue, 
accompanied by a breaking up and partial solution of the coloring matter 
of the blood, with the appearance of pus globules in it ; in two instances, 
there was effusion of a bloody purulent fluid into the joints a day or two 
before death : these results will be further noticed under the head of de- 
fective excretion and purification of the blood as an element of disease. 
Checked perspiration is a well recognized cause of disease, commonly of 
a febrile or inflammatory nature; but the sudden suppression of a foetid 
sweat in the feet, axillse, &c, has sometimes' been followed by such se- 



DEFECTIVE EVACUATION. 



51 



rious disturbance of the health, as plainly indicates that the matter thus 
excreted is of a noxious quality. 

The preceding are extreme results ; but the attentive observer will 
find that smaller degrees of the same causes, insufficient secretion, or 
insufficient evacuation of excrementitious matters, are among the com- 
monest sources of disorder; and it. is by a proper restoration of these 
functions that the almost universal domestic remedies, as well as the 
common pills and draughts of the surgery, prove so useful in preventing 
as well as in removing disease. We shall have many occasions to il- 
lustrate these facts. 

Numberless maladies arise from suppression or irregularity of the 
catamenial discharge, which appears to be a highly carbonized blood, 
and therefore its excretion gives relief. Diseases are not unfrequently 
excited or rendered active at the period of its total cessation. The same 
may be said of the secretion of milk. The disorders which these first 
produce are commonly connected with local or general plethora ; but 
eventually the quality of the blood in the body becomes altered as these 
excrementitious matters are suppressed. 

69. An artificial or diseased discharge or secretion, as that of a seton 
or issue, or from an ulcer or diseased membrane, or an unnaturally pro- 
fuse flow of an ordinary secretion — such as looseness of the bowels, if 
so long established as to have become habitual — cannot be suddenly 
suppressed without great risk of exciting disease. In the case of ha- 
bitual puriform or sanious discharges from setons, issues, and old sores, 
their sudden suppression has sometimes given rise to the most formida- 
ble symptoms, showing that a noxious matter had been thrown back 
upon the system ; and the fear of such accidental suppression, which 
cannot be always prevented, deters me from frequently employing these 
artificial drains in the treatment of disease. Habitual hemorrhages, as 
from the nose or rectum, and the practice of periodical blood-letting, 
cannot be abruptly checked w 7 ith safety. The maladies which result 
will vary with the predisposition ; but generally they are of the nature 
of local or general vascular fullness, or some disorder of secretion, or of 
the nervous system, arising from disturbances in the circulation. As 
examples may be named — congestion of the brain, apoplexy, congestion 
of the liver, various hemorrhages and inflammations, gout, epilepsy, 
palsy, hysteria, hypochondriasis, mania, &c. 

The suppression or too rapid removal of some cutaneous eruptions 
may be appended to this class. The diseases which it excites are some- 
times inflammatory or profluvial, as gout, rheumatism, diarrhoea, &c. ; 
sometimes more nervous, as chorea, epilepsy, asthma, dyspepsia, hys- 
teria, &c. 

70 (8). Defective cleanliness, ventilation, and drainage. — Much of the 
pernicious influence exercised by these causes might be referred to the 
last head; for there are few kinds of filth more offensive, few mephitic 
gases more foul, and few T descriptions of offal more abominable than those 
that are excreted from the animal body itself. And if, as we have seen, 
such matters are so injurious when not sufficiently eliminated out of the 
body, it is not surprising that they continue to be noxious, and may be- 



52 



EXCITING CAUSES OF DISEASE. 



come causes of disease after they have been evacuated, if proper means 
be not taken to remove them. The necessity of self-purification is il- 
lustrated by the instinctive habits of many animals and birds, which take 
much pains to cleanse themselves and their young, and in many instances, 
carefully remove excrements from their nests and habitations. Even 
plants are supposed by some botanists to exhibit a like provision for pre- 
servation against self-poisoning, in the constant spreading of their roots 
into new soil, uncontaminated by their own excreted matter. Yet, with 
strange disregard of all instinctive feelings, and indolent neglect of the 
plainest dictates of reason, human beings are found continually exposing 
themselves to the influence of their own accumulated filth, until disease 
is engendered and aggravated into pestilence, and the rate of mortality 
is doubled or tripled in the population.* 

Although the three particulars, neglect of cleanliness, imperfect ven- 
tilation, and defective drainage, operate much in the same ways, and are 
very commonly combined, yet with a view to suggest remedial means, 
it will be useful to consider briefly the modes in which each is known to 
excite disease. 

71 (a). Filth accumulated on the surface, consists of the inspissated 
matter of perspiration, together with any extraneous dust or dirt to which 
the individual may be exposed. The sweat is peculiarly rank and offen- 
sive in some persons, especially when accumulated during much mus- 
cular exertion ; and in some parts, as in the axillae, and perinseum, and 
betw T een the toes, is combined with an odorous principle, the disgusting 
character of which seems to be intended by nature to suggest the ne- 
cessity of frequent ablutions ; yet how many, and these not confined 
to the lowest ranks, are "content to live in dirt and stink," and often 
eventually to pay the penalty of their filthiness in various cutaneous 
diseases which are thereby induced! In young children, in females, 
and in many aged persons, the urine dispersed in the vicinity of the 
secreting orifice becomes an additional cause of irritation and offence. 
The accumulation of filth on the surface farther favors the propagation 
of vermin and of contagious diseases, especially the itch, from which 
few of the " mighty unwashed" are totally free. It also impedes free 
perspiration, and thus favors the production of rheumatism and diseases 
of the urinary organs, and others which sympathize with the skin. Neg- 
lect of cleanliness in clothes and dwellings, if not equally injurious by 
direct contact with the body, becomes hurtful by contaminating the air. 

* Every practitioner of experience has encountered many proofs of the potency of these 
causes, in generating and aggravating disease : and the profession and public have a most 
valuable collection of evidence on this point, in the following official reports: — 

Report from the Poor Law Commissioners on the Sanatary Condition of the Laboring 
Classes. 18-12. By E. Chadwick, Esq. 

Supplementary Report of the Practice of Interment in Towns. 1843. By E. Chadwick, 
Esq. 

First Report of Commissioners on the State of Large Towns and Populous Districts. 2 vols. 
1844. 

Second Report of ditto. 2 vols. 1845. 

A brief but comprehensive abstract of these reports, may be found in a small pamphlet, 
entitled. Letters on the Unhealthy Condition of the Lower Class of Dwellings, &c., by the Rev 
Charles Girdlestone. 1845. Longman & Co. 



DEFECTIVE VENTILATION. 



53 



[Mortality is invariably commensurate with the filth and destitution of 
the inhabitants, and the impurity of their abodes. — C] 

72 (6). Defective Ventilation, or insufficient change of the air of 
dwellings, might be considered to readily suggest its proper remedy by 
the feeling of suffocation induced; but it is not such a deficiency of 
oxygen, or excess of carbonic acid, as induces a stifling sensation, that 
does most harm: it is rather the scanty supply of fresh air that stints the 
vital processes without suddenly disturbing them ; and the gradual ac- 
cumulation of foul effluvia that slowly poisons, without exciting alarm. 
Persons are gradually brought to endure without complaint the impure 
air of a close room, which, to any one entering it from the open atmo- 
sphere, seems quite suffocating. Thus in the habitations of the poor, es- 
pecially in densely populated towns, it is not rare to find ten or fifteen 
crowded together in one small room, without any other supply of air 
than that which comes through chinks of the floor or window, or when 
the door is accidentally open. Among this class, the dread of cold pre- 
vails much more than the desire for fresh air ; and except in the height 
of summer, the solitary window may be rarely opened ; and during the 
night, when the. greatest number are collected together, every opening 
is kept carefully closed. During the w r inter, the same plan is pursued; 
but then, if there be any fire in the hearth, it will ensure a greater amount 
of ventilation. 

The habitual want of pure air especially exercises an unfavorable in- 
fluence on the state of the blood, and the functions of circulation and 
nutrition, causing pallidity of the surface, poorness of blood, imperfect 
development of the fibrous principle, which, instead of contributing to 
the nourishment of the muscles, degenerates into scrofulous or tuber- 
culous matter, the deposition of which in the internal organs or glands 
is favored by the weakness of the circulation. Exercise may in some 
degree counteract this effect of impure air: thus Dr. Guy found that in 
the close workshops of a printing establishment, the compositors, w T hose 
employment requires no exertion, fall victims to phthisis, in the propor- 
tion of 44 to 31J- per cent, of the pressmen who, while breathing the 
same air, use active bodily efforts. This difference is quite intelligible 
when it is remembered that active exercise, by increasing and extend- 
ing the force of the circulation, tends to remove congestions, to promote 
excretion, and by the activity of the respiratory function, enlivens and 
purifies the condition of the blood. Similar exercise in pure air would 
have much more salutary effects, the deaths from the same cause in out- 
door laborers not exceeding 25 per cent. 

Insufficient ventilation is by no means confined to the dwellings of 
the poor. In modern days, when workmanship of houses is more com- 
plete than it was in olden times, there are no longer the latticed case- 
ments, chinky floors, ill-fitted doors, and above all the roaring pile in 
the spacious hearth, that supplied abundant ventilation to the houses 
of our forefathers: now, in proportion as houses are "well built," every 
crevice is so thoroughly stopped, that our rooms, when closed, are well- 
nigh air-tight, and their occupiers are enclosed in an atmosphere which 
is deteriorating in proportion to the number assembled. Add to this the 



54 



EXCITING CAUSES OF DISEASE. 



vitiating effect of artificial lights, and of fires, the smoke of which may 
not freely escape for want of a due supply of air, and it will appear how 
modern houses often comprise the conditions calculated to produce this 
cause of disease. In public offices, schools, hospitals, churches, chapels, 
theatres, and other places where great numbers are collected together, 
the cause is still more fully in operation; and it is quite certain that not 
only is the public health much injured thereby, but much of the useful 
or agreeable objects of such assemblies is defeated through the discom- 
fort produced by the closeness and foulness of the air. 

The ill effects of deficient ventilation are increased by heat and mois- 
ture; the former operating not only by increasing the animal exhalations, 
but alsp by rarefying the air, and thus reducing the amount of oxygen 
in a given bulk: moisture probably acts in a degree in like manner, but 
also, as I conceive, by removing the difference between the air respired 
and that in the lungs which promotes that diffusion or interpenetration of 
gases on which the access of oxygen to the vesicular structure of the 
lungs depends. For be it remembered, the air taken in at each inspira- 
tion, is not enough to reach far in the tubes; its transfer into the air- 
cells is accomplished by the law of diffusion of gases, which operates in 
proportion to the dissimilarity between the gases, and difference in 
amount of contained watery vapor must exemplify this law. 

In certain occupations, gases or vapors of a positively noxious quality 
are engendered, and augment the evils of deficient ventilation. Such is 
the case in many chemical works, slaughter houses, and dissecting- 
rooms, soap, glue, and catgut manufactories, and in the employments in 
which materials are used containing mercury, white lead, and arsenic 
(§ 53). The deleterious operation of effluvia arising under these cir- 
cumstances, may be short of a directly poisonous effect, yet, by adding 
to the unwholesomeness of the atmosphere, it gradually undermines the 
health, and is best to be counteracted by a more efficient means of ven- 
tilation. 

73 (c). Defective drainage comprises much of the influences exer- 
cised by the preceding causes, filth and foul air; but it includes also 
circumstances that may exceed them in pernicious operation. The soil, 
which drains from habitations, contains, in addition to excrement, dirty 
water, washings and remnants of animal and vegetable matters used as 
food, and other offal; and all these, when mixed and stagnant, consti- 
tute the corrupting slough retained in cesspools and privies, and carried 
into sewers. The stench which these exhale, when opened, gives some 
idea of their deleterious influence; and the fearfully poisonous nature of 
the gases which they emit, has been proved by the sudden faintness and 
sickness, nausea, vomiting, and diarrhoea, which have attacked persons 
engaged in emptying them. Instances have occurred of individuals 
being speedily asphyxiated by the gases of cesspools; and where the 
result is not immediately fatal, a congestive or typhoid pneumonia en- 
sued which passed into gangrene in the first stage. (Chomel.) The pre- 
cise nature of the gases evolved is not fully ascertained ; but they 
obviously contain much sulphuretted and carburetted hydrogen, which, 
although known to be highly noxious, probably do not comprise the most 



EXTREMES OF TEMPERATURE. 



55 



deleterious part of these offensive effluvia. It is no wonder, then, that 
every ill-drained house should have a Pandora's box, ready to pour forth 
its evils whenever occasion offers; and always oozing them out in de- 
grees sufficient to impair the health of the inhabitants, and gradually to 
excite cachectic and other chronic diseases. Hence, as it appears in the 
several sanatary reports before cited, the mortality rises in a remarkable 
proportion in all those districts of towns where sewerage is absent or 
inefficient. The worst nuisance of this description is the cesspool with- 
out a drain from it; unemptied for months or years, and often imper- 
fectly covered, it continually poisons both air and water; and typhoid 
fever, diarrhoea, cholera, dysentery, dyspepsia, inappetency, and gene- 
ral weakness and mal-nutrition, are results of different degrees of its pes- 
tiferous operation. Scarcely less injurious, and more insidious in its 
operation, because the effluvium is less offensive, is the untrapped drain 
in connection with the sewers of large towns. This cause of disease 
exists extensively in London, not only in the street drains, which are 
always open and emitting the gases of the sewer, the bad odor of which 
is perceptible in certain winds, but also in the drains of houses which 
are either intentionally or negligently left open, or are not air-tight from 
the absence of water in the traps. Nothing is more common than to 
perceive the peculiar smell of the drain on entering a house, and in 
many instances I have found that this has proceeded from the trap left 
open, or dried up, and therefore inoperative, and requiring only the sim- 
plest expedient to stop the evil. When a single trap is open in a house, 
especially in the winter, when doors and windows are closed, and there 
is no adequate supply of air for the fires in the house, the foul air is 
drawn up from the sewer in a strong current, and quickly pervades the 
house from bottom to top, carrying with it a pernicious influence. It is 
surprising how ignorant servants and employers, and even professional 
men, are on this point, which so immediately concerns their health and 
comfort; and I have visited in many houses where this has seemed to 
be a cause of illness or impeded convalescence, in low nervous fevers, 
bowel complaints, influenza, neuralgia, headaches, and other ailments. 
In some instances, the leakage may be in consequence of the inroads of 
rats, or the displacement of the brickwork of the drains. It may be 
useful to state that, besides by the smell, which is not obvious to every 
one, the effluvia of drains may be detected by the darkening of white 
paint, and the early spoiling of meat in the lower basement story of the 
house. 

74 (9). Of all the exciting causes of disease, there is none so com- 
mon as temperature in extremes, or in sudden transitions ; cold, heat, 
and sudden transitions from cold to hot, or hot to cold. Both heat and 
cold have different modes of operation, and cause disease in different 
ways. 

Extreme heat and extreme cold are directly destructive to life. Heat 
above 180° coagulates the albumen of the blood, and thus obstructs the 
blood-vessels, and may cause other chemical changes of a disorganizing 
nature (§ 53): a part that has been raised to this temperature, therefore, 
necessarily dies ; it cannot live again. It is true that we occasionally 



56 



EXCITING CAUSES OF DISEASE. 



see boiling water at 212°, boiling oil at 600°, and red hot iron at 1000°, 
produce no other effect than violent inflammation and blistering of a part ; 
but that is because these bodies have been applied for too short a time 
to do more than violently stimulate the part, not time enough to raise it 
to the decomposing temperature ; a few seconds more, and the part would 
be killed. 

Cold below 32° freezes the water of the fluids ; and as it destroys the 
life of tender plants, so it kills parts of animals, whether by the expan- 
sion of the ice injuring the delicate organization, (Sir B. Brodie,) or 
whether from the mere stoppage of the circulation, or other cause, is un- 
known. The part may be afterwards separated from the living parts by 
a vital process of inflammation and sloughing. 

75. A disorganizing degree of heat, extensively applied, acts like a 
violent mechanical injury — such as tearing off or crushing a limb (§ 52). 
It directly depresses all the functions : the pulse becomes very weak, 
frequent, and sometimes irregular ; the muscular strength almost annihi- 
lated, and consciousness may be nearly or quite suspended. In this 
state, notwithstanding the stimulant properties of heat, and the inflam- 
mation which it generally excites, patients require stimulants, and they 
often die in a state of complete collapse, without any rallying or reac- 
tion. Extreme cold, also, if for some time applied to the whole body, 
depresses and paralyzes all its powers, even that of generating heat, and, 
therefore, of resisting cold. Sir Astley Cooper observed, that on plung- 
ing kittens into ice-cold water, the arterial blood did not become venous 
in the veins ; and Chossat found, in animals killed by cold, arterial blood 
in the left cavities of the heart. From a similar cause, the limbs become 
benumbed by extreme or continued cold : thus persons are drowned 
in cold weather much more speedily than in warm. With less intense 
degrees of cold, on the other hand, which do not destroy the vital pro- 
cesses, more oxygen is absorbed, more carbonic acid formed, and heat 
generated, which are the means by which animals resist cold. 

76. Heat which is insufficient to decompose, is directly stimulant. It 
excites the function of parts, and when generally applied, induces a state 
of fever. Thus when a person is in a vapor bath, or hot-air bath, the 
pulse quickens, the whole surface becomes red, full, and hot; there may 
be throbbing and pain in the temples, and a feeling of feverish oppres- 
sion, until a sweat breaks out, which relieves the superficial tension and 
fullness, and soon reduces the increased heat. Similar results may en- 
sue from confinement in overheated rooms; and if there be any tendency 
to local congestion or inflammation, particularly in the head, this excite- 
ment may be enough to produce it. The continuance of heat enervates, 
reduces the strength and appetite, and may excite a feverish state, with 
disorder of the liver. The oppressed breathing which is often felt in 
heated rooms may, according to the view of Liebig, be ascribed to the 
smaller amount of oxygen in the air rarefied by the heat; but it is pro- 
bable that this is not the only cause. 

A more partial exposure of the body to heat may produce still more 
disordering effects, if the part overheated be capable of suffering from 
the excitement. Thus solar or artificial heat to the head may cause 
severe headache, apoplexy, or inflammation of the brain. Heat to the 



COLD — MODES OF ACTION. 



57 



spine, as on sitting with the back near a large fire, is very apt to cause 
sickness and faintness, and, if continued, may induce convulsions. More 
local inflammations, as of the eye, ear, and skin, are frequently caused 
by exposure of the parts to heat. Gout may sometimes be excited in 
the feet by the same stimulus, and this is often attempted purposely. 

77. Cold, on the other hand, is directly sedative. It contracts tissues 
and vessels, especially the arteries, and thus at first renders parts pale 
and shrunk. In persons of feeble circulation, after bathing, the fingers 
are sometimes quite bloodless and numb from this cause; the cold having 
quite closed up the arteries.* But cold also retards the passage of the 
blood in the capillaries; the viscidity of the liquor sanguinis seems to be 
increased ; globules stick to the sides, or move but slowly, and the part 
soon becomes purple or blue, from the congestion of blood in it. 
This purple color is chiefly seen in parts much exposed, and where the 
blood habitually enters w T ith freedom, as the cheeks, ears, nose, and hands. 
There is also much internal congestion from the intropulsive operation of 
the cold — that is, the external parts being constricted and obstructed, 
blood accumulates more in internal parts, and the heart's force is more 
expended on these. This may in part account for the degree of stupor 
and ultimate insensibility into which persons exposed to extreme cold 
are apt to fall. In some such cases, there has been a flow of blood from 
the nostrils or ears ; the stupor has continued for hours after the heat and 
circulation have been restored ; and, in fatal cases, much serous effusion 
has been found in the brain. f 

78. Hitherto, w r e have considered the immediate operation of cold (§§ 
74, 77). But its indirect effects are more commonly known: these are, 
reaction, irritation, inflammation, and their consequences; and they will 
be more manifest where the cold has been partial, and the strength of 
the circulation generally not reduced. Thus, after a part has been ex- 
posed to severe cold, when restored to warmth, it becomes the seat of in- 
creased flow of blood, which causes redness, pain, and more heat; and 
various forms of inflammation may ensue, generally modified by the 
specific effect which the previous cold has exercised on the vessels and 
nerves ; varying also with the strength of the general circulation. Thus, 
as the indirect effects of cold in a part, we may have chilblain, gangren- 
ous or erysipelatous inflammation, and paralysis, or altered sensation. 
As much of the disease in these partial effects of cold, arises from the 
violence of the reaction and inflammation, and this depends on the sud- 
den return of heat and circulation in the part, it becomes an obvious in- 
dication, for frost-bitten limbs, to retard this return by cold applications, 
But Dr. Alison well remarks, that this precaution is not needed, where 
the sedative effects of cold have been more general; here warmth and 

* A similar effect may be seen under the microscope, on applying ice-cold water to the 
frog's web: the arteries contract to obliteration. This is contrary to the assertion of Poi- 
seuille. (See my Gulstonian Lectures, Med. Gaz., July 16, 1S41, p. 639.) It must be re- 
marked, that the elementary action of cold on the arteries is strictly stimulant, exciting their 
vital property of contraction; but its operation on textures and organs is sedative, because it 
impairs the circulation which supports their functions. So, too, we have found, that wbera 
it reaches the heart, it paralyzes its powers (§ 74). 

f Kellie, Ed. Med. Journal, vol. i. p. 304, quoted by Dr. Alison. 



5S 



EXCITING CAUSES OF DISEASE. 



stimulants may be used freely, for there is no fear of partial injurious 
reaction. 

79. We have hitherto chiefly considered the manner in which cold 
causes disorder in the parts to which it is applied; but this is not the 
most common mode in which cold excites disease. A person gets his 
feet wet, stands in a draught of cold air, or is exposed to cold when in- 
sufficiently clothed ; he afterwards becomes diseased — not in the feet, 
or the parts chilled, but in some internal part. He gets a sore throat, 
a " cold in the head" or chest, an inflammation of the lungs, a rheuma- 
tism in the limbs, a looseness of the bowels, a catarrh of the bladder, or 
any other disease to which he may be predisposed (§ 14). Now how 
does the external cold cause internal disease? How is the effect trans- 
ferred from external to internal parts? 

Dr. Alison supposes that the cold operates chiefly on the nerves, and 
that the sensation which it excites is conveyed also by the nerves to the 
internal organs, where its morbid effects become manifest. But it must 
be objected that the morbific effects of cold are by no means proportioned 
to the sensation, or known nervous impression, which it excites. A 
person may have his limbs aching and benumbed with general cold ; yet 
internal disease does not result. But if he has been exerting himself, is 
perspiring, and then gets his feet wet, or is otherwise exposed to cold, 
especially partial, wuthout continuing his exercise, although he may 
scarcely feel the cold, yet he will be pretty sure to catch cold, and to 
exhibit some one or other of its internal morbid effects. 

It would seem more probable, therefore, that external cold excites in- 
ternal disease by deranging the circulation, particularly that in the capil- 
laries. Cold checks the external secretion, the perspiration; it constricts 
and obstructs the vessels of the surface (§ 77), and must thus throw more 
blood inwardly, so that internal congestions are produced — these internal 
congestions impair the functions of the affected organs, especially those 
concerned in excretion (§ 68), and in other ways lay the foundation of 
disease. This intropulsive effect of cold will take place more readily, 
and to a greater extent, in proportion to the weakness or sluggishness 
of the capillary circulation. This may be weak naturally (§ 20) ; in 
this case, there is a constant liability to " take cold." Or it may be weak 
and relaxed from previous excitement, during fatigue (§§ 23, 24), or dur- 
ing sleep. Hence persons are more apt to catch cold after being in a hot 
room, after exertion, or w T hen asleep. On the other hand, the injurious 
effect of cold is lessened or prevented by a vigorous state of the capillary 
circulation, whether that vigor be natural, or excited by continued ex- 
ertion, stimulating drinks, or by febrile excitement (§ 17). 

On this view, we can understand why partial but continued cold, such 
as from draughts of cold air, wearing damp clothes, standing on cold 
stones, and the like, should be particularly injurious, even when the sen- 
sation of cold excited is not great. Such causes of cold, acting long on 
the same part, more completely constrict its vessels, check its secretions, 
thus more surely injure the balance of the circulation, and by throwing 
a corresponding amount of congestion inwardly, fix it in some part pre- 
disposed to disease (§ 14). 

When a person has thus taken cold, which he knows by general sen- 



COLD — MODES OF ACTION. 



59 



sation of coldness and weak circulation, rather than by any feelings in 
the part chilled, powerful measures which tend to restore the balance of 
the circulation, such as violent exertion, a hot or vapor bath, or stimu- 
lant drinks, may often yet prevent the further progress of disease. The 
general application of cold, if not long continued, is less injurious than 
that which is partial, both because it disturbs less the balance of the cir- 
culation, and because also it supplies the lungs with denser air, and 
therefore more oxygen ; and its impression on the nerves of the face and 
chest excites more energetic respiratory movements, which maintain the 
heat and the vigor of the circulation. Healthy persons rarely take cold 
when traveling on the top of a coach or in a perfectly open carriage, but 
they frequently suffer in a close carriage partially open. 

80. Susceptibility to the morbid effects of cold is to be diminished by 
means which invigorate the capillary circulation, especially those which 
promote that process of reaction by which cold is naturally resisted. 
Now nothing tends to increase this more than sudden artificial applica- 
tions of cold, as by cold bathing or sponging, followed by friction, exer- 
cise, heat, or stimulant applications, which promote the reaction (§ 16). 
The great art in usefully applying cold with these intentions, consists in 
using the cold in such manner and degree, and having the body in such 
a state before and after the application, that the reaction or glow, which 
is the sign of vigor in the capillary circulation, shall be most fully pro- 
duced. If, on the other hand, the cold be applied too long, or when 
the body is exhausted by fatigue, exertion, or other cause (§ 20), or is 
naturally too weak, depressing effects of cold will continue; there will 
be little or no reaction, and the sensations of languor and chilliness 
show that the cold has been injurious instead of beneficial. The addi- 
tion of salt to the water of baths, gives it a stimulant property which 
promotes reaction, and a similar influence results from the force or shock 
with which the water is applied. This shock excites deep and forcible 
respirations through an impression on the incident nerves ; and these 
are probably the efficient cause of the process of reaction which follows. 

The reaction which follows the judicious use of cold as a therapeutic 
agent, may prove serviceable, not only in resisting the further influence 
of cold, but also to remove congestions and irregularities in the circula- 
tion from other causes, and to excite in the capillaries and secernents new 
actions, which may supersede those of disease. It is thus that the " water 
cure" of Preissnitz chiefly operates; and although too powerful an agent 
to be entrusted to unskilled and unscientific hands, it promises to become 
a valuable addition to the means of combating diseases, particularly of a 
chronic kind. 

81. In the preceding remarks on cold, it must be borne in mind that 
the term cold is applied relatively, not absolutely ; cold is not a fixed 
temperature or range of temperature; but something considerably below 
the temperature of the body. Thus a body that has been warmed through- 
out to a heat of 98°, and kept in an excited state by that temperature, 
would suffer from a draught of air at 70°, which would be cold to the 
body, and produce the physiological and pathological effects of cold. 
But if the body had not been previously warmed, so that the temperature 
of most parts of the surface might not exceed 85°, or if, although lately 



60 



EXCITING CAUSES OF DISEASE. 



warmed, the energies of the body had not been exhausted by it, then 
air at 70° would feel pleasant, and produce none of the effects of cold. 
This is one of many facts which distinguish vital from physical proper- 
ties. Physical or chemical properties are generally affected by fixed 
temperatures, independent of previous circumstances : but vital proper- 
ties are variously affected through that power of adaptation by which 
they are enabled to maintain the same function in varying external cir- 
cumstances. 

It is thus that atmospheric changes in variable climates are fertile causes 
of disease. In this country, on a sudden change of wind, the tempera- 
ture sometimes falls 15° or 20° in the course of a day, and without any 
peculiar exposure, the body may become so chilled by the change, as to 
suffer to a degree amounting to disease. Internal congestions are the 
common result, but the seat of congestion and disorder will vary accord- 
ing to the predisposition. Thus, after the heat of summer, the organs 
most apt to suffer are the liver and abdominal viscera, which are disposed 
to disorder by previous excitement (§ 25): on the other hand, in the 
spring after the winter cold, the lungs and air-passages are more prone 
to derangement (§ 26). 



SECTION IV. 

II. NON-COGNIZABLE A GENTS. 

We now proceed to notice those causes of disease, the existence of 
which is inferred only from the fact that disease prevails under certain 
circumstances not well explained, unless we assume that causes do ex- 
ist (§ 12), although we cannot prove their existence in any other way 
(§ 53). These comprise the endemic, epidemic, and infectious causes of 
disease. In the reports of the Registrar General, they are termed zymotic 
(Cu^jy, a ferment), but inasmuch as this epithet involves an hypothetical 
signification of their mode of action, it does not seem expedient to adopt 
it here. 

I. ENDEMIC CAUSES. 

82. Persons living in a marshy district are often afflicted by a disease 
called ague, which does not attack those inhabiting dry lands. Again, 
the inhabitants of certain deep valleys are often affected with the swell- 
ing in the neck, called bronchocele or goitre ; the neighboring moun- 
taineers are not so affected ; and when those from below remove their 
residence to the mountains, they often lose the disease. These are 
instances of diseases which may be said to dwell among the residents 
in particular spots ; hence they are called endemic, in the people (s V 

In some cases, much doubt still hangs over the precise source of en- 
demic influence; some supposing it to be in the water, others in emana- 
tions from the soil ; but this doubt does not apply to the cause of agues, 



ENDEMIC CAUSES. 



61 



intermittent and remittent fevers, which have been clearly traced to effluvia 
from marshes, jungles, rice grounds, &c. It has been found that when- the 
wind blows across these marshes, the disease appears chiefly in per- 
sons residing to leeward of them, and not to w T indward; and it has been 
abundantly proved, that when the marshes are drained, the ague ceases. 
From these and similar facts, it is concluded that the cause of the ague 
is an effluvium, miasm, malaria, or bad air; an aerial poison, which is 
supposed to be inhaled with the breath, and absorbed into the system. 

83. The true nature of marsh malaria has not been determined. It 
has never been detected by chemical analysis. Professor Daniel con- 
jectured that the malaria causing the destructive endemic fevers of 
Western Africa, might be sulphuretted hydrogen evolved from the sea- 
water by the decomposing vegetable matter brought down by the rivers; 
but I am informed by Dr. D. B. Reid, that experiments made in the late 
unfortunate expedition to the Niger, have negatived this notion.* The 
microscope, rather than chemical analysis, may be expected to discover 
the nature of malaria. 

Although hitherto unknown in its nature, some knowledge of the 
general properties of marsh malaria has been obtained through its mor- 
bific effects. It seems to be heavier than air ; for persons occupying a 
ground floor suffer more than those living in upper apartments. Water 
seems to absorb or destroy it, for persons on board ship, or on an oppo- 
site side of a lake, are not affected ; w r hilst at a greater distance, a favor- 
able wind will convey the pernicious influence over land. A damp state 
of the air, however, favors its production ; good fires in a house give 
marked protection to the inmates. It seems to be attracted by trees; 
for the vicinity of trees is doubly dangerous, whilst places beyond trees 
are more free from its effects than others at the same distance. 

84. The chief points known with regard to the source of malaria, are, 
that it arises from the operation of the sun's heat on marshy ground, or 
on the banks or deltas of tideless rivers, after evaporation has proceeded 
to some extent; putrefaction of organic matter not being an essential 
part of the process. f The virulence of the malaria, as shown in the 
severity of the disease excited, and in the number which it affects, seems 
to bear some proportion to the heat which has led to its development. 
Thus the ague of this country, the pernicious intermittent of Italy, and 
the malignant intermittent of Western Africa and the West Indies, seem 
to arise from similar endemic causes, but differing in their virulence ac- 
cording to the degree of heat. A certain amount of moisture is, how- 
ever, required, for a very dry season, which desiccates a marsh, stops 
the malaria; and the deposit of the evening dew always favors its pro- 

* [Dr. D. Pereira Gardner reached the same conclusion as the late Prof. Daniel, as to the re- 
sult of experiments on the air of malarious regions (a). These views have been, however, 
entirely disproved by Drs. Mc William (6) and Morris Pritchett, who have shown that free 
sulphuretted hydrogen does not exist in the waters of the Nile — the locality from which the 
water with which Prof. D. experimented was obtained; and that which was detected in the 
specimens sent to England and there examined, was generated on the passage, by the de- 
composition of the contents of the bottles. — G] 

f Chisholm and Ferguson, Ed. Med. and Surg. Jour., vol. vi. : Trans. Roy. Soc. Edin., vol. ix. 

(a) [Am. Jour. Med. Sciences, April, 1843.] 

(6) [Medical History of the Expedition to the Niger, &c. Lond. 1843.] 



62 



EXCITING CAUSES OF DISEASE. 



duction (§ 83). Again, excess of moisture checks its development, so 
that a very wet season, as well as a very dry one, may render a marsh 
less unhealthy (§ 83). Extreme heat will not, however, diminish the 
malaria from the banks of rivers, since portions of these are never dry. 
For a similar reason, all the low shores of the Mediterranean are always 
malarious at the commencement of hot weather; the absence of a tide 
preventing that frequent salt washing and drainage which purifies other 
European shores. 

It is not only marshy or low grounds that engender malaria, although 
these are the situations commonly most favorable for its production. All 
that seems to be requisite is the continued operation of the sun's heat on 
moisture stagnant at or near the surface of the ground. I know instances 
in which ague has attacked persons living on a height of mountain lime- 
stone, forming a small table land below greater heights. So also some 
swampy lands are not malarious, particularly peat bogs, which show a 
remarkable exemption from decomposition and effluvia of all kinds. 

85. The morbid effects of marsh miasms are several : intermittent and 
remittent fevers of various types are the most remarkable of these, and 
they particularly affect the new residents; but the older inhabitants suf- 
fer from diseases of the liver and spleen, nervous affections, rheumatisms, 
dropsy, and cachectic complaints, and are generally short lived. The 
first operation of malarious poison seems to be on the quality and distri- 
bution of the blood, which in the worst cases becomes speedily darker 
in color and otherwise altered, and accumulates to an extraordinary 
amount in internal organs, where it suffers still further from its stagna- 
tion and want of purification by the ordinary excretions. The fit of 
an ague is the reaction (§ 16) of the vital powers against this decom- 
posing and cumulative influence of the poison on the blood; and if the 
vital powers are strong, and the dose of the poison not overwhelming, 
the fit successfully removes the internal congestions, and partially re- 
stores the purity of the blood by an increase of the excretions; but the 
poison being still in the system, reproduces similar effects after a longer 
or shorter interval. 

One of the most remarkable characters in the disease resulting from 
malaria, is the periodicity of their attacks, and the diminution or cessa- 
tion of the symptoms in the interval. This is probably due to the alter- 
nate- accumulation of the malarious influence in the body and the reac- 
tion of the vital powers against it. 

86. There can be little doubt that there are different kinds of malaria 
besides that which causes intermittent and remittent fever (§§ 80, 81). 
Thus yellow fever and plague are endemic diseases, probably arising 
from aerial poisons. The propagation and mortality of the latter, per- 
haps its very existence, are very much to be ascribed to the filth and im- 
purities of the towns where it prevails. These are cognizable causes, 
the operation of which in exciting and predisposing to disease has been 
already noticed (§§ 70—73, § 22). 

Some other epidemic diseases can be traced to other cognizable causes; 
as the Guinea worm, to drinking water containing its ova; the pellagra 
of northern Italy, and the plica of Poland, to neglect of cleanliness, and 
unhealthy modes of living. 



EPIDEMIC CAUSES. 



63 



II. EPIDEMIC CAUSES, 

87. There is another class of diseases, which, in their affecting many- 
persons in the same place and at the same time, resemble the endemic 
(§ 81). But they differ in this respect, that they do not regularly return 
at stated seasons (§ 84), nor are they confined to particular localities 
(§ 82), although they infest some more than others; but they attack a 
whole district, a whole country, — nay, almost a whole hemisphere — 
within a very short time ; often coming on without obvious cause ; pre- 
vailing for some time, then disappearing for an uncertain period ; per- 
haps recurring within a few months, or years, or not within the memory 
of man. These are called epidemics (stuS^oj), like a blight or per- 
nicious influence blowing on the people ; and therefore affecting a whole 
country at once. 

88. The cause of these diseases is supposed to be something in the 
atmosphere ; because the atmosphere is the only thing common to all 
the places so affected; but the nature of the cause is not known. It is 
true that some diseases, which seem to prevail epidemically, may be 
traced to the cognizable qualities, cold, heat, dryness, and moisture of 
the air (§ 74, et seq.). Thus diseases excited by cold sometimes pre- 
vail, like an epidemic, in the winter; those by heat, in the summer; 
catarrhs and quinsies abound in cold damp weather; croup and rheuma- 
tism become common during the prevalence of a cold east wind, in the 
spring; diarrhoea and dysentery are rife in the fruit season of the autumn. 
Others, again, such as dysenteries, fevers, scurvies, &c, have, in some 
instances, obviously arisen from deficient or contaminated food, bad water, 
or some distinctly cognizable cause (§§ 6<J, 70, et seq.). And as these 
causes belong to the class of cognizable agents before noticed .(§ 52, et 
seq.), it is unnecessary to advert to them here. 

89. But there are diseases occurring epidemically without any dis- 
coverable connection with season or temperature. Thus an epidemic in- 
fluenza may come on at any season of the year, rapidly spread through 
a country, and cease as unaccountably as it began. So, too, diseases 
that are usually excited by other causes, infectious and others — such as 
typhus and scarlet fevers, measles, small-pox, erysipelas, &c. — some- 
times prevail throughout a country so generally, and often with such 
peculiar characters, that some influence besides their common causes 
must be concerned in their sudden increase. The nature of this in- 
fluence is unknown; but it is called epidemic (§ 87). 

90. Lastly: various diseases, fevers, and inflammations, and almost 
all sorts of ailment, at some periods assume a remarkable character in 
common, or type (as it is called) ; for example, being attended with un- 
usual weakness, or unusual excitement, or a tendency to hemorrhage. 
This is called an epidemic or prevailing diathesis, or constitution. Thus 
at uncertain times, fevers, w r herever arising, and from whatever source, 
are more low, typhoid, or adynamic, than usual ; at the same time, ex- 
anthematous diseases generally partake of the same character; and even 
patients affected with inflammations do not well bear the usual deple- 
tions. Of late years, this constitution has more or less prevailed, and 



64 



EXCITING CAUSES OF DISEASE. 



may be contrasted with a period of twenty years ago, when an inflam- 
matory diathesis existed, and blood-letting was advantageously employed 
even in continued fever. 

91. It has been before stated (§ 88), that we are quite in the dark 
as to the nature of epidemic influences, or causes of disease. Many con- 
jectures have been advanced, some of them with much plausibility, but 
without any substantial support. Dr. Prout states that, shortly before 
and during the prevalence of the malignant cholera in this country, he 
noticed a small but decided increase in the average weight of the atmo- 
sphere, as if from the addition of some ponderous gas. At the same time, 
he remarked an unusual acidity in the saliva even of healthy persons, 
and such an absence of lithic acid from the urine, that he seems inclined 
to suppose that a disposition to form oxalic acid was referable to the 
same unknown cause which was then producing cholera (§ 60). 

92. Many analogical arguments may be adduced in favor of a favor- 
ite notion of Linnseus, that epidemic diseases are caused by animalcule 
tribes. This hypothesis [first broached by Kircher, and sanctioned by 
Linnaeus — C] has been ably advocated by Dr. Holland* and Dr. Henlef 
[and Dr. J. C. Nott of Mobile^ — C.J. Before I had seen the opinions 
of these authors, I had stated in my lectures some arguments in favor of 
this notion, which will be given under the head of infection. The chief 
facts which countenance this view, are the following : — 1. Epidemic dis- 
eases, in the uncertain periods and places in which their visitations 
occur (§ 88), resemble those of blights, or tribes of insects, which are 
known to appear and disappear without evident cause. 2. Proofs are 
accumulating of the occasional existence of parasitic animals and plants 
in living animals, and in some instances as causes of disease ; (as in the 
case of worms and other entozoa, acari in itch, the rot-worm in sheep, 
the mycodermatous vegetations in porrigo,§ conferva? in impetigo, aph- 
tha?, &c.) 3. The history and symptoms of some epidemic diseases, 
such as cholera and influenza, are not inconsistent with the hypothesis 
that they are caused by the sudden development of animalcules from 
ova in the blood. But there is a total want of direct observation in sup- 
port of this hypothesis ; and, perhaps, it may be objected against it, that 
the seasons at which epidemics sometimes appear (as cholera in winter) 
are not always those most favorable to the development of animalcule 
life." || 

* Medical Notes and Reflections, 1840, p. 597. 

t Pathological Researches, British and Foreign Medical Review, April, 1840. 

PNew Orleans Medical and Surgical Journal, 1848. — C] 
j Gruby, Comptes Rendus, t. xiii. Bennett, Trans. Royal Soc. Edin., 1842. 
|| The prevalence of the south-east wind was observed to be particularly favorable to the 
increase both of cholera and influenza; and I cannot but think that this had some con- 
nection with the general tendency exhibited by the former to spread chiefly from east to 
west. Has the morbific property of this wind aught to do with the haziness of the air when 
it prevails — a haziness seen in the country remote from smoke, and quite distinct from fog? 
What is this haze? In the west of England, a hazy day in spring is called a blight. 



INFECTION — KINDS OF. 



65 



III. INFECTIOUS CAUSES. 

93. The terms infection and contagion are applied to the production 
of a disease by a morbid matter proceeding from the body of another per- 
son who is, or has been, the subject of the same disease. The proofs 
that disease is thus propagated from one individual to another, are, first, 
the general one, that those who have intercourse with the sick are affect- 
ed in much greater numbers than those who have not (§ 12) ; and, se- 
condly, the direct and individual proof of infecting a healthy person with 
matter taken from a person in disease. This, although available only in 
some modes of infection, may be considered as a proof of the fact of con- 
tagion in general — that is, of disease propagating its kind. 

94. I have just alluded (§ 93) to differences in modes of infection: 
they may be further enumerated as follows: — 

(1). Infection through wounds, or an abraded surface; as in hydro- 
phobia, the morbid matter being contained in the saliva, or guttural 
mucus of the rabid animal ; and in cow-pox, the matter being contained 
in the specific vesicle, and acting on a puncture or abraded surface. 

95 (2). Infection by contact, different parts of the body being sus- 
ceptible of different diseases; as the urethra and conjunctiva in gonor- 
rhoea, the vicinity of the external openings of the passages in syphilis, 
the skin in scabies, the scalp in porrigo — the morbid matter generally 
proceeding from similar parts. 

96 (3). Infection by exhalation from the breath, perspiration or other 
secretion, conveyed through the air to the mouth and air-passages; as in 
the case of measles, scarlatina, hooping-cough, typhus, and other infec- 
tious fevers. 

97. Some diseases may be propagated in several of these modes ; 
small-pox, for instance, may be communicated by punctures in the skin 
(§ 94), by inoculation — application to the eye (§ 95) — and by diffusion 
through the air (96): and probably the same might be effected with other 
febrile poisons, if their precise source in the body were as clear as it is 
in small-pox. These different modes of infection merely show that the 
infecting matter can exist suspended in the air, as well as in a fluid or 
solid state ; and according to these conditions, it may get access to the 
system by different avenues. 

98. Many of those who are skeptical as to the reality of infection, aim 
their objections only against aerial infection, and do not question the 
other modes. But the difficult problem is, not that the infectious matter 
may be diffused through the air— our smell informs us that animal 
effluvia are constantly so diffused — but the difficulty lies in the fact of 
infection by any mode; that is, that disease should propagate its kind. 
There are only two parallel cases in nature, in which analogous proper- 
ties are possessed by matter. One is the case of what is called septic 
matter, leaven, or ferment ; a little of which introduced into organized 
matter will promote changes and decompositions — "A little leaven 
leaveneth the whole lump." This property is supposed by Liebig and 
other chemists, to be chemical, operating in the manner of heat, by al- 
tering the molecular relations of compound matter; but by Turpin, Cag- 

5 



66 



EXCITING CAUSES OF DISEASE. 



niard De la Tour and others, it is stated, that fermentation is caused by 
the production and growth of living molecules or vegetables, and that it 
spreads by the propagating power of these. This would transfer this 
case, that of leaven or ferment, into the next category (§ 99). 

99. The other case analogous to propagation of disease by infection, is 
the vital power of generation ; in this case, as in that of contagion, matter 
propagates its own kind in the animal and in the vegetable world. Does 
the matter of contagion consist of animal ova or vegetable seeds? Are 
infectious diseases the results of the invasions and operations of living 
parasites, disturbing in sundry ways the functions and structures of the 
body, each after its own kind, until the vital powers either fail, or suc- 
ceed in expelling the invading tribes from the system. (§ 16)? Such an 
opinion has been many times proposed, and is, in a degree, implied in 
the term incubation, (sitting on eggs to hatch them,) commonly applied 
to the period between the reception of the infection and the first appear- 
ance of the symptoms. In support of this notion, may be adduced the 
case of itch, which certainly infects by an insect, the itch-mite, and 
spreads by this animal's propagation; and the case of porrigo, or favus, 
which depends on a minute parasitic vegetable, and infects through its 
seeds or sporules.* But these, it may be objected, are instances of mere 
local disease, and by no means like the cases of infectious fevers and 
syphilis, which affect the whole system. 

The case of small-pox and cow-pox might seem to be more intelligible, 
because the infectious matter is found to reside in the incipient pustule ; 
but this throws no further light on the subject; and although M. Gruby 
has reported that he has found a few animalcules in the lymph of these 
vesicles, its disseminating property has not been traced to them. 

100. The parasitic nature of infectious matters may receive some sup- 
port from the little that is known of their general properties, which further 
deserve to be mentioned on account of their practical importance. In- 
fectious matter is destroyed by a temperature above 120° Fahr., and by 
strong chemical agents, especially chlorine; its activity is impaired by 
cold; and in case of aerial infection, by intense cold and free ventilation, 
it is rendered harmless. Hence many infectious diseases cease when hard 
frost sets in. On the other hand, warmth, closeness and filth increase the 
virulence of contagion, and become, as it were, a nursery of pestilence. 
Nothing tends to promote the spread of an infectious disease more than 
crowding together several who are suffering under it. Each one is a 
separate source of contagion; and if these sources are multiplied in an 
apartment, the air will be contaminated in proportion. This is the chief 
reason why, in fever hospitals and fever wards, medical attendants and 
nurses escape infection much more rarely than in hospitals where the 
fever patients are widely distributed among other patients. 

101. It may be useful again to point out the peculiarities which dis- 
tinguish infectious from endemic and epidemic diseases ; for these pecu- 
liarities are proofs of the reality of infection as a separate cause of dis- 
ease. 



* Schonlein, Muller's Archiv., 1839, p. 82. Gruby, Gazette Medicate, Juillet 17, 1841. 



INFECTION ENDEMIC EPIDEMIC. 



67 



Infectious diseases first attack individuals in any locality, then gradu- 
ally spread in the vicinity of those diseased, or in the direction where 
there is most human intercourse. "Where care is taken early and com- 
pletely to separate the diseased from the healthy, disease does not appear 
among the latter. 

102. Endemic diseases may simultaneously attack many individuals 
in certain localities only (§ 81); they do not spread beyond these locali- 
ties ; no separation of the sick from the healthy will save the latter, but 
removing the healthy to another spot gives them security. 

103. Epidemic diseases simultaneously attack numbers in any locality 
(§ 88): they increase not peculiarly in the vicinity of those first affected, 
nor in proportion to intercourse with them, but rather in proportion to the 
prevalence of other conditions that may be called predisposing or deter- 
mining causes (§ 19). 

104. It must not be forgotten that some diseases are suspected to 
originate and spread in two, or even all, of these modes. Perhaps this 
may be said of typhus fever, plague, cholera, and dysentery. It has 
been already mentioned that infectious diseases, as small-pox, scarlatina, 
and measles, are occasionally increased and modified by epidemic influ- 
ences(§§ 90, 91); and the same thing may be said of some endemic 
maladies. So also the aggravation of contagious and epidemic complaints 
by endemic impurities (§ 85), makes it plain that all the class of causes 
may operate conjointly. It is under such circumstances of aggravation, 
or under those of strongly prevailing predispositions, as from famine 
(§ 21), fatigue (§ 23), confinement (§ 22), or mental depression (§ 28), 
that this class of diseases becomes so destructive as to be called pestilen- 
tial, or malignant. 

105. The direct operation of most of this class of causes is depress- 
ing, and where they are strongest and prevail most, the resulting disease 
is one of depression, adynamia, asthenia, or prostration of the vital 
powers. These causes, as exhibiting a noxious property opposed to life, 
are therefore commonly designated specific poisons. But there is the an- 
tagonist principle of vital resistance in the system (§ 16), which leads 
to various processes of reaction, which may be exhibited in different de- 
grees, according to the relative strengths of the poison and of this resist- 
ing power; and likewise often according to various cognizable agents 
which simultaneously act as predisposing, determining, or co-operating 
causes. For instance, in warm weather the poisonous influences are 
generally strong (§§ 84, 100), and the bodily powers weak (§ 24); the 
resulting disease is one of more complete adynamia. In moderately 
cold weather, on the other hand, the specific poison is less active, and 
the system is ready to react, not only against it, but against the cold with 
which it may be combined; this causes a more inflammatory type in the 
consequent disease (§§ 79, 81). 



68 



ULTIMATE ELEMENTS OF DISEASE. 



CHAPTER II. 

PATHOLOGY (PROPER) — THE NATURE AND CONSTITUTION OF DISEASE. 

106. Disease is a change from the natural condition of the function or 
structure of the body (§ 6, et seq.) ; but the change is generally more 
or less compound, involving several elementary functions or structures; 
and it is obvious that we cannot obtain an accurate knowledge of the 
nature of disease until we have ascertained that of its component parts. 
As the anatomist and the physiologist examine structures and functions 
by separating or analyzing them into their constituent parts, before 
he contemplates them in combination, so should the pathologist study 
these constituent parts, or elements, in disease, before he can understand 
their combinations.* 

The chemist, in the examination of his subjects, finds that there are 
some principles or elements that cannot be analyzed or divided further; 
these he calls ultimate or primary elements : others, again, are simple 
compounds, which may be analyzed ; but they occur so constantly, and 
act so singly in compounding and giving properties to complex matter, 
that they are called proximate principles or secondary elements. A paral- 
lel case might be shown of physical science. 

107. So it should be with physiology and pathology. f There are the 
healthy and diseased primary or ultimate elements of structure — muscu- 
lar fibre, nervous matter, vascular fibre, and the elementary tissues of 
membranes, glands, skin, and other parts; and there are primary ele- 
ments, healthy and diseased, of function of these same structures — irrita- 
bility, tonicity, nervous properties, to which may be added, because at 
present we cannot analyze it, the power of secretion and nutrition ; and 
lastly, the constituents of the blood. And there are the secondary or 
proximate elements of disease, composed of the preceding primary ele- 
ments, but still simple in comparison with the complex conditions of dis- 
ease which they combine to produce. 

* A neglect of this precept has greatly retarded the advancement, nay, even the forma- 
tion, of pathological science. Men have begun with the very complex problems of inflam- 
mation and fever, before they have made themselves acquainted with the elementary pro- 
perties of textures or even of vessels. The result has been, that the most profound reasoning 
and ingenious speculations have been wasted on non-entities, such as spasm of the extreme 
vessels, increased action of the capillaries, &c. : and even observation has been confused by 
the complexity of the subjects brought under it. 

"j" I have pursued this synthetic mode of teaching general pathology, in my lectures, from 
the year 1839 to the present time. I am not aware that it has been fully used by any other 
writer, although several (as Andral and Carswell) have partially recognized it in their di- 
visions of the objects of morbid anatomy; and my friend Dr. Symonds has adverted to the 
parallel of chemistry, and actually employed the term proximate principles of disease, in 
the same sense in which I use it. — Tiveedie's Library of Practical Medicine, vol. i., Pathological 
Latroduclion. 



PROXIMATE ELEMENTS OF DISEASE. 



69 



108. The varieties of disease affecting these several elements may be 
comprehended under the heads of degree and kind ; degree, including ex- 
cess and defect, or alterations of plus and minus: and kind, relating to 
changes not comprised under these heads, but otherwise expressed 
by the term perversion. By applying these heads to the elements of 
structure and function, we obtain a simple and comprehensive classifi- 
cation, which embraces all the important topics of general pathology. 

109. The following table presents this classification applied to the 
primary or ultimate elements. 



PRIMARY ELEMENTS OF DISEASE. 



FUNCTION. 

Irritability, 

Tonicity, 
f Sensibility, 
J Vol. motion, 
J Reflex action, 
^ Sympathy, 

Secretion, 



Excess, Hypertrophy. 
| Defect, Atrophy. 
^ Perversion, Degeneration, &c. 



PRIMARY CONSTITUENT. FUNCTION. DISEASE. STRUCTURAL DISEASE. 

Contractile fibre - 

Nervous structure 

Secreting structure 

Constituents of the Blood: — 
Red particles, 
Fibrin and white globules, 
Albumen, 
Oil, 
Salts, 
Water. 

Changes of the Blood: — 
By Respiration, 

— Secretion, 

— Assimilation, 

— Foreign matters. 

110. In the choice of proximate or secondary elements of disease, we 
must be more arbitrary and less comprehensive; otherwise we shall en- 
croach on the domain of special pathology. The vascular system and 
the nutrient function so intimately connected with it, present us with 
the best and most important examples of proximate elements, compris- 
ing, as they do, two or more of the preceding ultimate elements, (irrita- 
bility, tonicity, constituents of the blood, secretion, &c.,) yet so universal 
throughout the body as to belong to the province of general pathology. 



PROXIMATE ELEMENTS OF DISEASE. 
C General 



The blood in / 
circulation ^ 



Defective — Anaemia 



Excessive— Hyperaemia i 



^Perverted- — Cachaemia 



Partial 
General — Plethora-; 



Partial — Local hy- 
peraemia 



\2 Increased — Sthenic. 

•3: 

2 Diminished — Asthenic. 

S3 

Incr eas e d — D eter min ation. 

o 

Diminished — Congestion. 



£ Partly inc. j) Jnfl 



Partly dim. 



anima- 
tion. 



70 



ULTIMATE ELEMENTS OF DISEASE. 



f Defective — Atrophy. 

^ Excessive — Hypertrophy. 

'Degenerations. 
I Perverted — ■{ Deposits. 
V Growths. 



Nutrition of / 
Textures 

Perverted — < 



These primary and secondary elements of disease are the especial sub- 
jects of general pathology. By the study of them we become acquainted 
with the materials of disease, and their relations to each other; we learn 
how special diseases arise, and of what they consist : how they produce 
their phenomena and effects, how they are to be known, distinguished, 
and classified. Out of such a knowledge, where it is correct, sufficient, 
and combined with an ample acquaintance with the properties of remedial 
agents, arises the rational method of relieving, curing, and preventing 
disease, the great ends of the art of medicine. 

I readily admit that our knowledge of these elements or principles in 
pathology, is as yet too limited to be entitled to rank as a complete sci- 
ence ; but I think that the attempt to describe and illustrate them will be 
useful, not only by making available all that is known on the subject, but 
also by showing what is not known, and needs investigation : thus sug- 
gesting fit subjects for further research. 



FUNCTIONAL OR DYNAMIC DISEASES. 

PRIMARY ELEMENTS. 



SECTION I. 



PROPERTIES OF THE MOVING FIBRE. IRRITABILITY. 



111. Irritability, irritable contractility, or the property of contract- 
ing on the application of a stimulus or exciting agent, is the distinctive 
property of muscular fibre. Although some physiologists maintain that 
this property is derived from some part of the nervous system, they have 
not produced any conclusive proof to that effect: it is, therefore, more 
philosophical to retain the Hallerian view of intrinsic irritability.* 

* Dr. M. Hall ascribes irritability to the spinal marrow; but he mentions an experiment 
which is conclusive against this view: — "During the half lethargic condition of the frog in 
winter, the entire cerebrum and spinal marrow may be removed, by slow degrees, at con- 
siderable intervals; the circulation is nevertheless good." — Gulstonian Lectures, 1842, p. 60. 
The irritability of the heart, therefore, is unimpaired. The late experiments of Dr. John Reid, 
on muscular irritability, are strongly in support of the Hallerian doctrine. 



EXCESSIVE IRRITABILITY. 



71 



It may become excessive, so that the contraction is too violent for the 
welfare of the part or of the system. This constitutes spasm or con- 
vulsion. The excess of irritability may be manifest in three ways: — 1. 
By an excessive strength and degree ; 2. By an inordinate quickness or 
promptitude; 3. By the unusual duration of the contractions. 

112 (1). Excessive strength of muscular contraction is exemplified 
in the violent action of the heart during exertion or other excitement; 
and in the extraordinary muscular power of a delirious patient, who can 
master persons naturally stronger than himself. This exaltation of the 
natural property may depend on the excessive stimulus, as of blood in 
the heart, or of nervous excitement in the case of the delirious patient ; 
or it may arise from the muscles being over-fed with blood. 

113 (2). Inordinate readiness or quickness of contraction constitutes 
mobility of muscle, a slight stimulus causing it to contract. This often 
co-exists with want of power or completeness in the contractions. It is 
exemplified in the irritable heart, which, although acting very frequently, 
does not expel its contents so vigorously as in health. It is seen in the 
quick nervous movements of irritable persons, who are at the same time 
weak. The bowels show it in that irritable looseness formerly called 
lientery, in which food is quickly passed little altered; and it is instanced 
in the irritable bladder, which will not hold even an ounce of urine. 
The pathological cause of this kind of inordinate irritability is either an 
undue flow of blood to the muscle, which exalts its natural property, or 
a predominance of irregular nervous influence, which unduly excites this 
property: thus it is often excited by irritations of the motor nerves, or of 
their columns or fibres. But the most remarkable examples are given 
in the extreme case of convulsions or clonic spasms — that is, sudden con- 
traction, alternating with relaxation, as seen in chorea, epilepsy, and 
convulsive hysteria, where it affects the voluntary muscles ; and in the 
palpitating heart, which beats irregularly and out of rhythm. 

114 (3). An unusual duration of muscular contraction constitutes 
tonic spasm or cramp, in which the contraction is strong, and not alter- 
nated, as usual, with relaxation. Such spasms are not unfrequently felt 
in the. calves of the legs; and in the different muscular canals, the gullet, 
the stomach, the intestines, and the glottis, which occasionally present 
this state of continued contraction. In most of these cases, it is accom- 
panied by pain more or less severe, and may lead to serious obstruction 
to the function of the organ. When in a more moderate degree affecting 
the voluntary muscles generally, it constitutes catalepsy, in which, from 
the muscles remaining contracted, the limbs will retain whatsoever atti- 
tude they are placed in, until the spasm is over. But the extreme ex- 
ample is tetanus, in which the spasms are so violent and so enduring, 
that they may be said to squeeze the patient to death. The pathological 
cause may be, as in other modifications of irritability, either an irregular 
supply of blood to the muscle, or irritation, direct or indirect, of the motor 
nerves by which the muscles are excited. 

115. Remedial Measures. — These must depend on the cause of the 
excessive irritability. Where there is increased flow of blood to the part, 
blood-letting, derivants, sedatives, and other remedies for determination 
of blood, maybe proper. Firm pressure on muscles affected with spasm 



72 



ULTIMATE ELEMENTS OF DISEASE. 



or cramp, will promote their relaxation. I have succeeded in opening 
the jaw in trismus, by using strong steady pressure on the masseter mus- 
cles. Where the cause is nervous irritation, narcotics are the most effec- 
tual; and some of these, from their peculiar efficacy in allaying spasm, 
are called antispasmodics. The most powerful of these are stramonium, 
belladonna, sulphuric ether, in draught or inhaled, opium, and Indian 
hemp. Where irritability is combined with weakness, tonics are often 
serviceable, especially the metallic tonics, and bark. In such cases the 
muscles are usually w T eak and ill-nourished, and their excitability is de- 
pendent on exalted function of the excito-motory nerves ; the remedies 
will therefore be noticed under the head of nervous diseases. 

116. Muscular contractility may be defective chiefly in two modes. 
1. In force (§ 112); as in the weakness of voluntary muscles during 
severe illness, after fatigue (§ 68); or under the influence of a depressing 
poison or shock (§ 55); and in the weakness of the heart under similar 
circumstances, and in faintness, or in the sinking which precedes death. 
This weakness is caused by the exhaustion of previous exertion, or by want 
of a due supply of blood, which is necessary to maintain all functions; 
or it may proceed from an influence positively depressing or destroying 
the muscular power, as in the case of sedative poisons, as tobacco, sul- 
phuretted hydrogen, &c, and probably concussion and other violent in- 
juries to the organization. The extreme effect of these agents is to 
cause paralysis, or complete loss of irritability, which, affecting the 
heart, constitutes death by syncope. Muscles sometimes lose their irrita- 
bility by more gradual causes, such as rheumatic inflammation, the action 
of lead, &c. Muscles are reduced in power either by over-excitement 
or exertion on the one hand, or by disuse on the other: this is exempli- 
fied in the paralysis of the sphincter after over-distention of the bladder, 
torpor of the bowels after the operation of an active purgative, &c, and 
in the weakness and ultimate palsy of the muscles of an anchylosed limb. 

117 (2). Muscular irritability may be deficient in readiness to con- 
tract (§ 113), as in the sluggish movements of a person whose irritability 
has been lowered by opium; and in the slow pulse caused by digitalis, 
and by some cerebral affections; and in some cases by blood-letting or 
low diet. It is by no means clear why the same agents should lower in 
some cases the strength, and in others the promptitude in contraction ; 
and in many other respects, the laws of irritability require further inves- 
tigation. A benumbing degree of cold greatly reduces the irritability of 
muscles ; yet the sudden dash of cold water will sometimes restore power 
reduced by exhaustion or sedatives. 

118. Although it has never been proved that muscular irritability is 
derived from the nervous system, yet the illustrations already given plainly 
point out that it is much under its influence. The nerves are the proper 
medium by which the voluntary muscles are made to act, and through 
the nerves the motions of the involuntary muscles are influenced, as in- 
stanced in the operation of mental emotion on the action of the heart 
(§ 69). Hence diseases of muscular action generally rank with nerv- 
ous diseases. Thus disease of the brain may cause a cessation of 
muscular motion by suspending volition ; and disease of the spinal 



TONICITY. 



73 



marrow or nerves may do so by intercepting the influence of the will: 
in either case, motion of a muscle ceases, not from disease in itself, but 
for w T ant of its proper stimulus. In fact, under these circumstances, 
muscular irritability sometimes accumulates (§ 111), and is brought into 
action, by slight impressions reflected from the spinal marrow. Thus, 
in complete paraplegia, or loss of motion of the lower half of the body, 
convulsive movements may be excited in the lower extremities by tic- 
kling the soles of the feet : in other cases of paralysis, they may be pro- 
duced by electricity. 

119. Remedial Measures. — As usual, these will vary with the cause of 
the defective irritability; where it proceeds from exhaustion, repose is 
the obvious indication. But even here, in extreme cases, and more par- 
ticularly in those of the second head (§ 117), it maybe necessary at once 
to excite the defective irritability by stimulants, especially those of the 
more diffusible kind, as ammonia, brandy, and other spirits and essen- 
tial oils; whilst the feeble circulation and restoration of muscular power 
may be aided by heat and frictions. The large quantity of stimulants 
borne by patients whose irritability is reduced by accident or disease, is 
a remarkable feature in their history. A person faint from great loss of 
blood (§ 71), a crushed limb (§ 55), or a sedative poison, will bear four 
or five times more brandy than would be sufficient to intoxicate him 
under other circumstances. Electricity and the dash of cold water 
should be mentioned among temporary means of exciting defective irri- 
tability. Strychnia and cantharides given internally, are reputed to re- 
store pow T er to paralyzed muscles ; but the same agents act much more 
energetically when directly applied to the affected part by means of blis- 
ters. So likewise stimulant frictions, w T arm douches, and such means of 
promoting a vigorous circulation throughout the weakened muscles may 
assist in restoring their strength ; and generous diet, with tonics and a 
healthy air, render the blood richer in fibrin, by which the muscles are 
nourished. 



SECTION II. 

TONICITY. 

120. Tonicity, or tone, is a property possessed by all muscular struc- 
tures, and by some which are hardly accounted muscular. It is a tend- 
ency to slow, moderate contraction, not essentially terminating in re- 
laxation ; but it keeps tbe parts in which it resides in a certain degree 
of tension. This tone keeps muscles and limbs in their places when at 
rest, and out of their places when dislocated : if one set of muscles is 
paralyzed, the tone of their antagonists draws the parts in an opposite 
direction, as we see in paralysis of the portio dura on one side of the 
face. A similar property is possessed by the intestinal tube, the urinary 
bladder, the air tubes, and the middle coat of the arteries, and gives 
them a constant tendency to contract on their contents. In these, but 
particularly in the arteries, it performs an important part, both in health 



74 



ULTIMATE ELEMENTS OF DISEASE. 



and in disease. By this the arteries contract, when they cease to 
receive blood from the heart, and thus are found empty after death. It 
adapts them to different degrees of fullness, yet maintains in their walls 
a certain tension favorable to equality in the motion of the blood. 

It has been asserted, that tonicity is quite distinct from irritability; 
and although irritable fibres possess tone, tonic textures are not irritable. 
This is not true with regard to the arteries ; for I have many times distinctly 
seen them slowly contract, and remain contracted, at a point to which an 
irritant, mechanical, chemical, or electric, has been applied. The late 
discovery, by Henle, of a structure distinctly muscular in arteries, con- 
firms this observation. I have proved, in like manner, the irritability of 
the air-tubes, which move more rapidly under a stimulus than the arte- 
ries; whilst that of the intestines is still higher in degree, but still infe- 
rior to that of the oesophagus and voluntary muscles, the contractions of 
which, on the application of a stimulus, are abrupt, and immediately 
followed by relaxation. So far, then, it appears, that tonicity is influenced 
by the same agents which excite irritability; but another agent, tempe- 
rature, seems to affect them differently (§§ 74, 75). Cold increases 
tonicity and impairs irritability. Under the influence of cold, vessels 
generally, but especially arteries, shrink in size very remarkably;* and 
the muscles and other textures present a firmness and contraction which 
impede the quickness of motion characterizing the highest degrees of 
irritability. Under the influence of heat, on the other hand, although 
muscles are relaxed, they are more irritable, and the pulsations of the 
heart are more frequent. 

Cold and heat, therefore, become the best tests for tonicity; and by 
their means we find this property to be possessed by textures which are 
not distinctly muscular; I mean, the veins and the cutis, which, in a re- 
markable degree, contract with cold, and become relaxed with heat.f 

Now this property, tonicity, is a very important one in the animal 
economy, its natural condition being very necessary for the preservation 
of health, and its modifications being concerned in causing and consti- 
tuting disease, more particularly in the vascular system. Practical men 
have long admitted the existence of something of this kind, without de- 
fining or localizing it ; and the terms tone and atony, bracing and relaxa- 
tion, tonic and relaxing remedies, become quite appropriate in connec- 
tion" with this property. Let us notice some of the characters of its ex- 
cess and defect. 

121. Where there is an excess of tonicity, the muscles are so firm that 

* This fact must be familiar to every one who has noticed the difference of the pulse 
when a limb is cold and when it is warm. But I have seen it more forcibly illustrated by 
experiment. On plunging into cold water the aorta of an ass just dead, it contracted so 
closely as to obliterate its cavity; and it required some force to pass the little finger into it. 
The crimping of the flesh of fish is referable to the same principle. 

f It is difficult to assign the limit between textures that are irritable and not irritable. 
Thus some large venous trunks, as the cava, have been found by Valentin to exhibit slight 
contractions on the sympathetic nerve being irritated; and fibres like those of an unstriated 
muscle, have been found in their coats. The irritability of the dartos is well known; but I 
have frequently seen the skin of the trunk and limbs contract, and cause the projection of 
the papillse (presenting the appearance of the cutis anserina), on gently scratching or tic- 
kling the surface, the appearance being confined to the vicinity of the part tickled. 



DEFECTIVE TONICITY. 



75 



there is scarcely room for supple motion ; the pulse is hard, tense, and 
often slow, yet there is scarcely any interval between the heart's beat 
and the radial pulse. The capillary circulation is active, and the ex- 
tremities warm ; but owing to the tense state of the vessels and of the 
skin, the secreting organs do not act freely, the urine is high colored, 
the bowels are disposed to be costive, and the skin to be dry and hot. 
The vascular system is in a state of high pressure, under which any 
weak part may give way, and induce local congestion or flux, active 
hemorrhage or inflammation, apoplexy and gout ; but there is less than 
usual proclivity to suffer from cold, endemic and infectious influences, and 
others of a depressing character. The causes of excessive tonicity may 
be an over-nourishing and stimulating diet; with want of sufficient 
exercise; a dry bracing air; tonic medicines, such as iron and bark; 
the excitement of fever, &c. 

122. Remedial Measures. — In such a state blood-letting will reduce the 
tension of the vessels, but only for a time. As long as the tonic fibres 
are too much braced, and the pulse hard, the secretions will be defective, 
and the vessels will fill again and renew the evil. The measures best 
suited for this state of excessive tone, are those tending to relax the tonic 
fibre, and increase the secretions; such as warm bathing, exercise, su- 
dorifics, aperients, and diuretics, with moderate diet. It is probable that 
some remedies, such as antimony, reduce directly the tone of the vascu- 
lar fibre, acting as relaxants. We shall have to advert to this subject 
again under the head of inflammatory fever, of which the element, ex- 
cessive tone of the vascular system, is a chief constituent. 

123. "Where tonicity is defective, the muscles are flabby, and incapable 
of continued exertion, but sometimes are too irritable, with the tremu- 
lousness of debility (§ 113). The heart likewise is irritable, and often 
exhausts its strength in palpitation; the pulse is soft and yielding; it 
may be full when slow, and sharp when frequent ; but it is without firm- 
ness or endurance, and is easily accelerated. Another distinctive cha- 
racter is its retardation, increasing the interval between the heart's beat 
and distant pulses; so that the radial pulse is often felt after the second 
sound of the heart is heard (§ 121); the tubes being less tense, the 
pulse-wave is slower than usual (§ 120). Sometimes the absence of 
that tightening of the walls of the arteries, by which the tonic fibres con- 
trol their movements, permits their mechanical elasticity to come into 
play, and this reacting after each stroke of the heart, gives that peculiar 
reduplication or rebounding of the pulse, which has long been described 
under the term dichrotous pulse. This is often observed in convales- 
cence from fevers and other diseases, after the subsidence of vascular 
excitement. A loose, relaxed state of the vessels renders the circulation 
in distant parts weak, so that the extremities are cold, whilst the head 
and internal organs may be congested. Sudden exertion or change of 
posture may disturb the circulation and cause faintness or giddiness. 
Want of tone also in the stomach and intestines causes indigestion and 
costiveness, and permits them to become distended with wind and accu- 
mulating feces. The secreting organs, irregularly supplied with blood, 



76 



ULTIMATE ELEMENTS OF DISEASE. 



are also liable to disorder, being either scanty, depraved, or profuse and 
watery. 

It is quite obvious that a person in such a condition must be prone to 
various diseases. He has no resisting power (§ 16) against malaria, in- 
fection, or other depressing agents. If he is exposed to cold, the blood 
is readily driven through the weak vessels into the interior (§ 79), where 
it causes congestion or inflammation. The weak intestines have no 
power to expel offending matter from them (§ 57). Thus the system in 
a state of atony is open to the action of many exciting causes of disease ; 
besides being itself in many respects on the verge of disease, especially 
congestion and its consequences, and other derangements of the circu- 
lation. 

The causes of loss of tone are various debilitating influences (§ 28 et 
seq.), such as continued and exhausting excitement of the vascular sys- 
tem (§ 64), continued heat, especially with moisture, confinement in 
impure air, defective nutrition (§ 63), imperfect excretion (§ 68), &c. 
Muscles lose their tone from want of exercise, and blood-vessels from the 
continued operation of cold (§ 77). The tonicity of the arteries is liable 
to be influenced remarkably by the nervous system; and we shall here- 
after find that a relaxation of the arteries of a part is the chief cause of 
local determinations of blood. 

124. Remedial Measures. — The proper remedies for defective tonicity 
are tonics, which are agents that tend to increase the tone of the whole 
system (§ 120), particularly of its muscular and vascular parts. We 
have already stated that cold has this effect in a marked degree (§ 30), 
and in truth, cold, properly applied, is one of the best tonics which we 
possess. For this purpose its application should be sudden and too brief 
to cause depression or any of its morbid effects. The shower-bath and 
plunge-bath are the most effectual forms; and free sponging, with cold 
salt water, is applicable even to weak subjects. A pure bracing air and 
much exposure to it, with moderate exercise, have also useful tonic 
effects. There are many medicinal tonics, the most effectual of which 
are bark and its preparations, medicines containing iron, and the mine- 
ral acids. Generous living may be considered a part of a tonic plan, in 
so far as it tends to enrich the blood, which sustains tonicity, as well as 
all other vital properties. 



SECTION III. 

FUNCTIONS OF THE NERVES. — SENSIBILITY. 

125. Certain parts of the nervous system being known to the instru- 
ments of sensation, we have no difficulty in tracing diseased sensibility 
to this system : and as this system consists of a medullary centre, and 
of nerves converging from various parts to it, so we find that alterations 
in the property may depend either on disease of the centre, causing dis- 
order of general sensibility, or on disease of one or more of the nerves, 
causing disorder of local sensibility. These we shall now notice. 



EXCESSIVE SENSIBILITY GENERAL. 



77 



DISEASES OF GENERAL SENSIBILITY. 

These may consist in — 1, excess; 2, defect; 3, perversion. 

126 (1). Excessive sensibility is more or less present when the nerv- 
ous centres are excited in the early stage of their inflammation or of 
determination of blood to the head ; where there is intolerance of light, 
noise, and motion. A similar condition exists in hydrophobia and teta- 
nus from mere excitement, without inflammation. But short of these, 
sensibility is excessive in some persons, either congenitally (§ 41), or 
as a consequence of disease (§§ 31, 34). Such persons are commonly 
called nervous; they are worried with trifles; startled at shadows; dis- 
tracted by noise or bustle; never free from some ache or pain: for almost 
every feeling is suffering; and what in others would be slight pain, in 
these amounts to agony. Hence they are perpetual invalids, quite unfit 
for the rugged path of life, over which they, as it were, w T alk barefooted 
and thin-skinned. If real disease attack them, its nervous symptoms 
are so much exaggerated, that a medical attendant is apt to fall into the 
error of either ascribing all to "the nerves," or of measuring the disease 
by the severity of the symptoms. This over sensibility is generally con- 
joined with excess of irritability, and want of tone(§§ 113, 123). Other 
nervous functions, such as sympathy and reflex action, are also often aug- 
mented or in disorder. The symptoms connected with sensation most 
frequently present, are neuralgic pains of various parts, excessive sensi- 
bility of the surface, headache, pain in the back or left side, and spinal 
tenderness. 

127. The pathological cause of increased general sensibility is proba- 
bly a slighter degree of the same cause which induces it in the early stage 
of encephalitis, an undue supply of blood to the posterior columns of the 
spinal marrow, the corpora restiformia, and the parts of the cerebral mass 
concerned in sensation. This local determination of blood may result 
from original development; but it may also be a consequence of inflam- 
matory affections of the encephalon, of irregularities in the menstrual 
functions, or of the reaction ensuing after great Josses of blood, all of 
which are known to be sometimes the precursors of morbid sensibility. 
On a future occasion, in connection with the subject of irregular distribu- 
tion of blood, we shall endeavor to point out why great losses of blood 
and other causes of sudden weakness are sometimes followed by exces- 
sive sensibility. The extreme refinements and luxurious habits of the 
upper classes, with more excitement for the mind than exercise for the 
body, and for the feelings than for the understanding, are well calculated 
to foster this over sensitive state. 

128. Remedial Measures. — The medicines most directly in opposition 
to this element of disease are narcotics or anodynes, such as opium, hen- 
bane, hemlock, Indian hemp, &c, administered internally, or, in some 
instances, applied externally; as where muriate of morphia is sprinkled 
on the skin deprived of its cuticle by a blister. These diminish nervous 
sensibility; and in proportion as this is exalted (§ 126), the system will 
bear larger doses. But where the increased sensibility depends on in- 
flammation or vascular excitement of the nervous centres (§ 127), the 



78 



ULTIMATE ELEMENTS OF DISEASE. 



proper treatment will obviously be that to be hereafter described as anti- 
phlogistic. Again: where the excessive sensibility arises from the nerv- 
ous excitement of irregular circulation, from general weakness (§ 116), 
and loss of tone, (by no means an uncommon combination,) tonics (es- 
pecially the metallic) (124), and stimulants (119), as well as narcotics, 
are the proper remedies. Weakness, softness, and slow transmission of 
the arterial pulse (123), and absence of fever or permanent heat of skin, 
are the chief symptoms of such a condition. In these and other common 
cases of morbid sensibility, country air and exercise, cold or tepid bath- 
ing, especially with the shower-bath, plain food for both mind and body, 
early hours, and an avoidance of all enervating habits, are often more 
conducive to the cure than any medicines. 

An anodyne influence, more powerful in degree than that induced by 
any other agent, although transient in duration, is that resulting from 
the inhalation of the vapor of sulphuric ether, which has, during the last 
year, been extensively used, first in America, and subsequently in this 
country. The operation of this agent, and of nitrous oxide gas (which 
has a similar effect), is on the sensorium, rather than merely on the sen- 
sitive nerves. In most instances, if continued for a sufficient time, it in- 
duces complete insensibility, so that the subject may undergo the most 
severe surgical operation, and a female may go through the process of 
parturition, without suffering any pain. In many cases, however, espe- 
cially where the inhalation has been less prolonged, or less impregnated 
w T ith ether, sensibility is blunted, but not destroyed, and the patient 
makes movements, and may utter expressions, indicative of slight pain, 
yet has no recollection of it when restored to consciousness. The memo- 
ry seems to be more affected than the perceptive function. The power 
of voluntary motion is suspended in about the same ratio as sensibility ; 
but the reflex motions of the eyelids, breathing, &c, are lowered, but not 
abolished, unless the inhalation be continued so long as to induce com- 
plete asphyxia. 

The operation of ether vapor is obviously narcotic, like that of opium 
and alcohol ; and is more speedy and transient, because it passes freely 
and directly through the lungs into the arterial blood, and affects the 
brain, and is as promptly dispersed by its diffusion throughout the body. 
It has been maintained by many, that it operates by its interference with 
the respiration, inducing a degree of asphyxia ; but so far is this from 
being the case, that its best effects are produced when the respiration is 
steadily maintained; and it has always appeared to me that the end to 
be aimed at in the administration of ether-vapor, is to narcotize, as far as 
possible, without too much embarrassing the breathing. This is difficult 
to accomplish without a freer supply of oxygen than atmospheric air con- 
tains ; and I should expect safer and more satisfactory results from the 
inhalation of a mixture of ether vapor with oxygen gas, which might be 
continued with safety for a much longer period than with the vapor and 
air only. 

Although the chief influence of etherization is transient, yet by saving 
the nervous system from the shock of intense temporary pain, during an 
operation or paroxysm of suffering, it often prevents that consequent nerv- 
ous irritation and exhaustion which are so injurious to the vital powers, 



DEFECTIVE SENSIBILITY. 



79 



and which favors the return of the painful attack. Thus in neuralgic 
and painful spasmodic affections, the removal of one or more paroxysms 
by etherization may break the habit of diseased action, and effect a per- 
manent cure. 

129 (2). Defective general sensibility, in its extreme degree, is exem- 
plified in coma, from the circulation in the sensitive centre of the nerv- 
ous system being impeded by pressure, congestion, or other obstruction 
(§ 52), or from narcotic influence. Thus a person in a fit of apoplexy, 
or poisoned by opium, has lost all feeling, as well as voluntary motion. 
When the blood becomes impure by retention of excrementitious mat- 
ter, as in suppression of urine, a like stupor occurs (§ 68). Very 
rarely anaesthesia exists — that is, loss of sensation, without loss of motion. 
But short of these degrees, there are some who congenitally (§ 44), from 
disease (§§ 31, 34), or from age (§ 48), are deficimt in sensibility — feel 
less than other folk. All their feelings are obtuse, and their actions 
slow; they have no intense suffering or pleasure. Such persons have 
also little irritability, but much tone of fibre, and are remarkable for their 
immunity from many diseases. But they are the more liable to others, 
such as fullness of blood, apoplexy, gout, costiveness, and the various 
evils which these may bring. They contrast well with the over-sensitive 
in this, that disease, when it occurs, may be latent, advance far, and be- 
come dangerous before it is felt ; and may imperceptibly increase until 
it is incurable, or until sudden death ensues. 

130. Remedial Measures. — When obtuseness of feeling arises from 
fullness, obstruction, or pressure of blood in the nervous centres, the 
treatment will consist in attempts to remove these by depletion, deriva- 
tion, and other means to be mentioned under the head of disordered cir- 
culation. Where there is no actual disease present, but merely a torpor 
of the sensitive function, mental excitement, bodily exertion, the cold 
dash and friction are the best means of arousing the nervous system 
from its state of lethargy. The insensibility from narcotics and from 
retained excrementitious matters should be counteracted by means calcu- 
lated to eliminate the stupefying matter by the natural outlets, such as 
purgatives, diuretics, emetics, &c. It is doubtful whether we have any 
medicine capable of directly increasing sensibility. Strong tea and 
coffee perhaps have the best claim to such a property. What effect 
would arise from electrifying the spine and occiput ? Stupor and im- 
paired sensibility may arise in a state of anaemia, as in cerebral syncope, 
and in children or females who have lost much blood, this is from stag- 
nation of the blood in the brain. Under such circumstances, the pallor 
of the skin and weakness of pulse would indicate stimulants as the best 
means of restoring sensibility. 

131 (3). Perverted general sensibility is often manifested by those in 
whom there is also increased sensibility (§ 126), but its character is in 
the peculiarity of the sensations which are experienced. Thus sensa- 
tions of tingling, prickly heat, trickling cold, in various parts ; feelings 
of a lump in the throat, a hot ball in the side, a fluttering at the stomach, 
and illusions of the special senses, may severally and variously affect 



80 



ULTIMATE ELEMENTS OF DISEASE. 



persons whose sensibility is modified more in kind than in degree. Such 
persons may also have a depraved appetite, craving for sour things, 
cinders, mortar, and all manner of filth. These symptoms generally 
occur in females, often in connection with irregular menstruation ; there- 
fore, they are called hysterical : but their pathological cause must be 
sought in the nervous system, the functions of which, probably from irre- 
gular supply or bad quality of the blood which supports them, become 
disordered. The remedial measures indicated for this condition are, there- 
fore, those calculated to remove its cause : chalybeates and other tonics, 
with pure air, nourishing food, and other means which improve the 
quality, and equalize the distribution of the blood. Narcotics and seda- 
tives may be useful as temporary palliatives. In rare cases, the general 
sensibility is perverted by structural change in the nervous centres, such 
as softening of the cerebral structure. 

DISEASES OF SENSIBILITY OF PARTS. 

132. The feelings of a part may be excessive, defective, or perverted. 
This may be illustrated by experiment. By irritating or striking a nerve, 
pain is produced in the part to which it is distributed, and the sensibility 
of the part remains exalted — that is, it feels tender, or painful afterwards. 
By pressing on the nerve, a new and perverted sensation, of tingling and 
pricking, with numbness, is caused. By pressing more strongly, or 
dividing the nerve, the feeling is further impaired or altogether destroyed. 
Similar effects may be produced by a tumor, ligature, effusion, or other 
cause pressing on a nerve in its course. Disease of the nerve, or of a 
part of the spinal or cerebral matter connected with it, may likewise 
modify the sensation of parts. Thus inflammation of the sheath of the 
ischiatic or trifacial nerves may cause first neuralgic pain, and afterwards 
numbness in the parts to which the nerve is supplied. There are other 
painful affections which are to be considered and treated, as cases of 
exalted sensibility, such as the irritable (as Dr. Billing observes, errone- 
ously so called) breast, testicle, uterus, &c. 

1-33. But the function of sensation, as other functions, depends on the 
supply of blood to the extreme distribution, as well as to the trunk and 
origin, of the nerves. Hence if blood does not circulate freely through 
a limb, the sensations are impaired ; and if it passes too freely, the sen- 
sibility is exalted, and there may be itching, tenderness, or even pain. 
In organs of special sensation, the senses are modified, together with 
the common feeling : thus in disease of the optic nerve or retina, there 
will be intolerance of light, or specks and clouded vision, or even blind- 
ness; in the ear, ringing, and beating noises, or deafness, besides the 
affections of common sensibility, itching, tenderness, and pain. 

134. At the orifices of passages into the interior, there are peculiar 
kinds of sensibility connected with the functions of ingestion and eges- 
tion; these modified are elements of disease. As examples of such ex- 
cessive sensibility, may be enumerated thirst, craving, nausea, tenesmus, 
and painful micturition: of impaired sensibility, anorexia, and paralysis 
of the rectum and urethra. 



DISEASED SENSIBILITY LOCAL. 



81 



135. When we come to internal parts, we have only to consider their 
sensibility when exalted by disease. We do not know that they natu- 
rally possess any feeling. Of the ordinary processes, as of the passage 
of food and feces in the alimentary canal, of the movement of the lungs, 
of the heart, and of the blood through the vessels, we are not conscious ; 
but under the influence of disease, we become painfully sensible of se- 
veral of these motions. This excessive sensibility is developed by in- 
flammation, as in pleurisy, peritonitis, meningitis, &c, or by irritation 
by mechanical or other means, as in colic, biliary and urinary calculi, 
gastralgia, perforation of the stomach or intestines, &c. It is very re- 
markable that pain from these, which is perhaps severer than any, should 
arise so suddenly in parts which give no evidence of common feeling. 

136. In many instances we are to regard pain merely as a symptom 
to be removed only by means which remove its cause, the lesion which 
produces it (§§ 132, 133) : but in many cases, on the other hand, although 
a symptom, it constitutes a chief element of the disease, and one against 
which remedies must be expressly directed. Thus it is in neuralgia, 
gastralgia, nephralgia, colic, dysmenorrhcea, and perforated intestine. 
So long as the excessive pain lasts, all the functions suffer (§ 66), faint- 
ness and exhaustion ensue, and if no relief comes, the prostration may 
be fatal. Here to mitigate or remove the pain is a first and pressing in- 
dication. Again; in some other cases where the pain is less severe, it 
may be very hurtful, by interfering with important functions. Thus the 
stitch of pleurisy impedes the breathing; the pain of tenesmus and the 
irritation of the stomach or windpipe cause efforts at straining, vomiting, 
and coughing, so violent, that the functions are thereby kept in a state 
of disturbance, and the strength is exhausted. Here it may be neces- 
sary to treat promptly for the pain on account of its immediately perni- 
cious effects. 

137. Remedial Measures. — Where excessive sensibility depends on in- 
flammation, antiphlogistic measures will generally soon remove it. Where 
it lingers after the inflammation, is out of proportion to it, or is independ- 
ent of it, then anodynes become the chief remedy. The most powerful 
of these is the inhalation of the vapor of ether above noticed ; which is 
fairly applicable to the mitigation or removal of local pain of a tempo- 
rary character. The most potent of fixed anodynes are opium and its 
active principles: but these have morbid effects (impairing the secre- 
tions) (§ 70), which sometimes render them less eligible than the weaker 
narcotics, hemlock, henbane, stramonium, belladonna and Indian hemp. 
The stronger preparations of aconite and its alkaloid are powerful ano- 
dynes, and are very valuable as outward applications; but their depress- 
ing operation on the heart renders them unsafe for internal exhibition. 
These different anodynes are used both internally and externally. One 
of the most effectual methods with which I am acquainted, for relieving 
severe local pain, is the endermic application of morphia: for this pur- 
pose a blister is applied to the painful part, and when fully risen, the cu- 
ticle is completely removed, and the denuded surface sprinkled with one 
or two grains of a soluble salt of morphia (the acetate or hydrochlorate) 
in fine powder; which may be repeated once or twice daily, according 



82 



ULTIMATE ELEMENTS OF DISEASE. 



to the urgency of the pain. The effect is first anodyne, then narcotic 
on the system, with much less than usual of the injurious effects of 
opiates by the mouth. The application loses all effect, so soon as the 
blistered surface becomes dry. Counter-irritation and warmth are also 
means of relieving pain. The pain of gastrodynia may often be removed 
by a sinapism to the pit of the stomach — that of colic and dysmenorrhoea 
by hot fomentations, or bags of hot sand or salt, &c. In other cases, 
painful feelings may be relieved by such pressure on the part as will 
counteract tension, and diminish without stopping the flow of blood 
through the part. Painful affections occurring with a weak circulation, 
particularly if intermittent in their attacks, are often removed by tonics ; 
thus neuralgia has been successfully treated with quinine and iron, he- 
micrania with quinine, or liquor arsenicalis. 

138. We are not possessed of equal means of restoring lost sensi- 
bility. Stimulant applications and frictions are serviceable where the 
defect arises from deficiency of circulation in the part; and strychnia or 
cantharides given internally, and electricity used topically, perhaps may 
have some little effect in exciting the functions of the nerves, but more 
doubtfully in regard to sensation than to motion. 



SECTION IV. 

DISEASED VOLUNTARY MOTION OR EXCITO-MOTION BY THE WILL. 

139. The function by which certain nerves convey the impulses of 
the will to voluntary muscles, may become disordered, and its pheno- 
mena constitute an element of disease. Some of these have already been 
noticed under the head of diseased irritability (§ 113); and it was there 
observed that the error is more commonly in the nervous influence which 
excites the muscles, than in the property of the muscles themselves. 
This is the case in most convulsive diseases, and in those cases of para- 
lysis which depend on injuries of the voluntary nerves, or of those parts 
of the spinal and cerebral system which are the channels of volition. A 
brief illustration of these diseases will suffice to correspond with those 
of diseased sensation. 

DISEASES OF GENERAL VOLUNTARY POWER. 

140. The voluntary motor power may be said to be generally in ex- 
cess, when the brain is excited by strong emotions or feelings (§ 66), 
by stimulating liquors (§ 56), and by the hurried circulation of frenzy, 
or phrenitic delirium. Hysteria, as usual, can supply like examples. 
The strength and rapidity of movements displayed in hysterical cases 
are sometimes astonishing; yet they are obviously voluntary movements, 
for they are often performed rhythmically, or to a tune, as in dancing. 
The dancing of tarantulism, and the extravagant exertions of the fanatics 
called jumpers, would seem to arise from an erethism of the part of 
the nervous system concerned in voluntary motion. Short of disease, 



DISEASED VOLUNTARY ACTION. 



83 



a naturally high voluntary power is evinced in the energetic and active 
movements of some persons, who excel and delight in feats of strength 
or agility. Mere muscular strength will not suffice without nervous 
energy to act on it. 

141. General volition is more or less defective in apoplectic coma, 
stupor from various causes, pressure, congestion, narcotism, &c, where 
other nervous properties are also impaired (§ 129); in trance, catalepsy, 
and nightmare ; in a less degree also in cases of lethargy and weakness 
from over-exertion (§ 68). This defect may be sometimes suddenly in- 
duced by terror, surprise, &c. (§ 69), which for a time take away the 
power of motion. Hence the fabulous power of the Gorgon's head ; and 
the signification of the expressions, petrified with astonishment, motion- 
less with terror, fascinated, and the like. The muscular power (§110) 
is not lost in these cases, but only the influence of the mind over it — 
that is, volition. 

142. Examples of perverted voluntary power may be found in chorea, 
delirium tremens, and some analogous affections called hysterical. In 
these volition may be often also defective (§ 141), but it is not always 
so; only each act of the will is perverted in its performance. The will 
sets muscles in motion, but the wrong muscles, or too many, too for- 
cibly, or irregularly, so that the resulting action is not in accordance 
with the will. 

PARTIALLY DISEASED VOLUNTARY POW T ER. 

143. We can scarcely point out examples of partial excess of volun- 
tary motion. The convulsive movements of voluntary muscles are 
quite involuntary, and have been noticed under the head of diseased 
muscular action (§ 113); but it was there mentioned that they may arise 
from irritation of the nerves, independent of the will. Hysteria does, 
however, furnish examples of excessive movements of one limb or part 
of the body, so far amenable to mental influence as to be excited and 
timed by ideas in the patient's mind. These cannot be said to be wholly 
involuntary ; but are the results of a wilful impulse, perhaps too strong 
to be easily resisted. 

144. Partial defect of voluntary power is very common, and, like 
local defect of sensibility, may be traced to partial disease of the motor 
(anterior) columns of the medulla and prolongations ; or to disease of, 
or pressure on, a motor nerve in its course; or to a disordered condi- 
tion of the ultimate distribution of the nerve, or of the circulation sup- 
porting its function. Thus paralysis of voluntary motion in an extre- 
mity or a whole side (hemiplegia), may arise from disease in the optic 
thalamus or corpus striatum of the opposite side: these being the chan- 
nels of communication between the cortical seat of the sensorial functions 
and will, and the motory columns and nerves. Lesions of the motory 
(anterior) columns within the spine, may intercept more or less the vo- 
luntary power of those parts supplied with spinal nerves from below the 
diseased point. Thus a lesion in the lower cervical portion may paralyze 
the upper and lower extremities and whole trunk, (except the diaphragm, 
which is supplied by the phrenic nerve:) a lesion in the dorsal or lumbar 



84 



ULTIMATE ELEMENTS OF DISEASE. 



portion, paralyzes only the lower half of the body (paraplegia), or lower 
extremities. Or the disease may be more partial, paralyzing one nerve 
only, as the portio dura, causing distortion of the features; or the ninth 
nerve, causing difficult articulation, &c. The lesion of the nervous tex- 
tures here alluded to, may be structural change, as tumors, effusions, 
or hemorrhage, or only an altered state of the blood-vessels of the part. 
Severe cold or continued pressure will impair voluntary power in a limb, 
by checking the free flow of blood, which is essential to the proper func- 
tion of the nerves as w T ell as of the muscles. Hysteria affords numerous 
examples of volition impaired in parts, as in loss of voice and power of 
articulation, retention of urine, paralysis of limbs, &c. ; these affections 
may come on quite suddenly, and as suddenly cease. 

145. Remedial Measures. — Excessive voluntary power is rarely an ele- 
ment of disease for separate treatment. As part of the excitement of 
the nervous centres, it may be reduced by sedatives of different kinds — 
depletion, antimonials, and cold to the head, being the most effectual, 
where the excitement is attended with determination of blood; morphia, 
and other narcotics, where the excitement is more purely nervous. The 
violent exertions of maniacs are wonderfully controlled by the cold douche 
to the head, sometimes with nauseating doses of tartar emetic. The 
vehement movements of those excited by fanaticism and tarantulism are 
ended by exhaustion ; they might probably be checked by a timely duck- 
ing with cold w T ater; which is often successful in hysteria. 

146. The treatment of defective volition w T ill consist in means calcu- 
lated to excite the nervous centres, directly or through the medium of 
the circulation. Agents which restore free circulation of healthy blood 
through the nervous centres and branches, generally improve voluntary 
power. Thus a stimulant draught may raise the failing strength of a 
person fainting. By warmth and friction, one w T ho is benumbed w T ith 
cold recovers the. use of his limbs. Sleep or rest will restore voluntary 
power exhausted by fatigue. Sudden and powerful mental excitement, 
as by a fright, has been known to restore voluntary power which had 
been long lost. A lady w 7 ho for several years, had lost the use of her 
lower extremities, was startled by a rat running near her: having an ex- 
treme antipathy to the animal, she made an effort, and sprang upon a 
table near; the power, however, did not remain, for she could not get 
down again. A more permanent cure of impaired volition has been ef- 
fected by the excitement of religious fanaticism, as in the cases of the 
supposed miracles of Prince Hohenloe, Miss Fancourt, &c. As we have 
found that such mental excitement sometimes causes excessive voluntary 
motion in healthy persons (§ 140), so we perceive that, suddenly applied, 
it may restore it where defective. 

But sometimes volition is defective from pressure on, or congestion in, 
the brain, which prevents the due motion of the blood through it, as in 
plethoric lethargy, or apoplectic coma : here depletion and derivation may 
sometimes restore the power. In the lethargy of narcotism and asphyxia, 
the volition is often restored by means which excite strong sensations, 
and reflex actions, as dashing cold water on the face and chest, ammonia 
or other stimulating vapors to the nostrils, electric shocks, stinging with 
nettles, &c. The trance or coma of hysteria may often be removed by 



DISEASED EXCITO-MOTION. 



85 



a turpentine injection, or croton oil purgative, which acts both as a re- 
vulsive to the vessels and a stimulant to the nerves. 

Pervert volition will require various treatment according to its kind; 
that of delirium tremens being corrected by narcotics, especially opium ; 
that of chorea, by nervous tonics, especially iron and zinc. 

147. The treatment of locally diseased voluntary power will generally 
commence with attempts to remove its cause, which we have found to 
vary too much both in seat and nature to admit of an elementary state- 
ment of remedial measures. Those for defective voluntary power com- 
prehend the complex subject of the treatment of paralysis, which com- 
monly comprises means calculated to restore to its proper state the circula- 
tion through the affected part of the nervous system, and sometimes, also, 
means which stimulate this part by exciting agents, such as electricity, 
stimulating frictions, and blisters ; and strychnia and cantharides given 
internally, which are supposed to have a directly stimulant action on the 
motory columns and nerves. 



SECTION V. 

DISEASES OF REFLECTED AND SYMPATHETIC NERVOUS INFLUENCE. 

148. The nervous property by which various movements and processes 
connected with organic life are excited, may be disordered, and its al- 
terations are remarkable constituents of many diseases. The contractions 
of all the sphincters, of the oesophagus, the glottis, the iris, the eyelid, 
and the regular action of the muscles of respiration, seem to be sustained, 
independently of the will, by a nervous influence conveyed by afferent 
nerves from the respective parts or surfaces to the spinal marrow, and 
reflected from it through the efferent nerves to the muscles connected 
with these parts. The full establishment of this physiological principle 
we owe to Dr. Marshall Hall. 

149. The increase of this involuntary excito-motory power is instanced 
in the spasm of the throat, and sometimes of the sphincters, in hydro- 
phobia, tetanus, and some hysterical affections. The hurried respiration, 
the convulsive cough, violent retching, and hiccup, which are occasionally 
presented in these and other nervous diseases, may also be in part traced 
to an undue influence of the excito-motory nerves of organic life. These 
actions are sometimes excited by sensations (§ 134), as the breathing 
by feeling of want of breath, cough by tickling in the air-passages, 
retching by nausea, &c. ; but it is where either there are no such sensa- 
tions, or where they bear no proportion to the violence of the actions, 
that we are warranted to conclude that the excito-motory function is itself 
exalted. 

A similar exaltation of the excito-motory function, independent of sen- 
sation and volition, is exemplified in the voluntary muscles, when they 
are deprived of sensation and voluntary motion by disease in the brain 



86 



ULTIMATE ELEMENTS OF DISEASE. 



itself, or cutting off communication between the brain and spinal cord, 
without materially injuring the cord itself (§ 118). Thus, in paraplegia 
from injury of the upper part of the spine, the excito-motory power of the 
nerves of the lower extremities is exalted, and tickling, or mere touching 
the soles of the feet or legs, will produce convulsive motions, although 
all voluntary power and sensations be wholly lost.* This phenomenon 
is sometimes so readily produced as to be a cause of much disturbance 
to the patient, the mere touch of the bed-clothes exciting troublesome 
startings. The same thing occurs in hemiplegia, but less distinctly, as 
the cerebral influence is rarely here so completely intercepted. I have 
known, however, the convulsive motions of a paralyzed limb so violent, 
in a hemiplegic patient, that it was necessary every night to fasten it 
down to the bedstead to enable the patient to get sleep. 

An instance of involuntary excitement of the muscles occurs in the 
symptom of " fidgets," which often arises from irritation reflected from 
the lower part of the intestinal canal, or from the uterus ; and another is 
seen in the sudden retraction of the testicle by the contraction of the cre- 
master, on touching the inner part of the thighs, in disease of the kid- 
neys, and other urinary organs. 

150. Under this head, we must also glance at convulsions, w T hich, ac- 
cording to Dr. M. Hall's views, and consistently with the phenomena of 
disease, must be referred to an irritation of the true spinal system. This 
irritation may be centric, as in epileptic and apoplectic convulsions from 
disease in the head, and those from loss of blood ; in which cases, the 
spinal and prolonged medulla being excited, the excito-motory influence 
radiates to the limbs and muscles generally ; or it may be eccentric, com- 
mencing with irritation of the extremities of some afferent nerve, which 
transfers it to the spinal centre, whence it is again reflected generally or 
partially. Such are the convulsions arising from teething, uterine, intes- 
tinal, and renal irritation ; and a slighter degree is exemplified in the 
rigor caused by the sudden impression of cold on the surface, or by pass- 
ing a bougie into the urethra of a nervous person. 

151. Partial spasms, caused by reflected irritation, are exemplified in 
cramp in the legs from acrid matter in the colon, in diarrhoea and cho- 
lera; spasm of the glottis from a bone sticking in the pharynx, &c. More 
familiar examples of the same class of reflected irritation are found in 
sneezing from irritation of the nares, winking from irritation of the con- 
junctiva, coughing from irritation of the glottis, retching from irritation of 
the fauces, efforts to evacuate the rectum and the bladder from irrita- 
tion of these parts respectively. But it must not be forgotten that all 
these latter examples are connected with obvious sensations ; and they 
imply increased excito-motory influence only in those cases in w T hich they 
are out of proportion to these sensations. 

152. But some of the most remarkable instances of reflected irritation 

* The same phenomenon is exhibited in a high degree in the decapitated frog, in which 
touching the surface excites convulsive movements. A still more interesting illustration 
sometimes occurs in animals or persons whose cerebral power (sensation and voluntary 
motion) is impaired by opium or other narcotics; spasms or convulsive actions of the mus- 
cles being induced by tickling or pinching the skin, which shows the excited state of the 
reflex or spinal function. 



DISEASED EXCITO-MOTION (REFLEX). 



87 



are displayed in the involuntary muscles, the heart, and the muscular 
fibres of the air-tubes and intestinal canal. Thus, inordinate action of 
the heart (palpitation) is commonly caused by irritating matters in the sto- 
mach or intestines, kidneys, or other viscera (§§ 51, 54); nay, we shall 
afterwards find, that the heart is liable to be excited by considerable 
irritation in any part of the body, as in fever and constitutional disorder. 
The spasm of the intestines in colic is induced by reflex irritation result- 
ing from acrid matter in them; for if it were from direct irritation alone, 
the spasm would only affect the part touched by the offending matter.* 
The spasm of the bronchi, so suddenly occurring in spasmodic asthma, 
also sometimes arises from intestinal irritation. It has long been sup- 
posed, and is still a common opinion, that these morbid sympathetic 
movements are due to the direct nervous connection which the great 
sympathetic nerve establishes between the respective organs ; but this 
supposition assumes, what experiment has not proved, that the ganglia 
of this nerve are either centres of reflection,! or sources of nervous influ- 
ence, which is still more inconsistent with the latest researches. So far 
as we yet know, the spinal marrow is the centre of reflection in these as 
in all other examples of reflex action which we have been considering, 
although the sympathetic be the medium of communication.^ 

153. When phenomena of inordinate reflex actions are general or ex- 
tensive, as in convulsions, tetanus, and paraplegia, we must refer them 
to an undue excitement or erethism of the spinal and prolonged medulla ; 
but the more partial examples may arise from similar excitement of a 
small portion of it only, or of the incident (afferent) nerve of the part 
which occasions the phenomenon, or of the excito-motory (efferent) nerve 
of the part which exhibits the phenomenon. 

If we seek to know the causes of this excitement, we shall find that, 
as in excess of other vital properties, it is sometimes referable to an in- 
creased flow of blood through the spinal marrow or its nerves, or the 
branches of the sympathetic nerve. Thus the early stage of inflamma- 
tion of the spinal cord, or of its sheath, is attended with convulsions or 
tetanic spasm. It is very probable that the spinal excitement (convul- 
sions) occurring in epilepsy and apoplexy, is in part due to the flow 
through the medulla being increased in proportion as that through the 
brain is impeded: a consideration of the causes of convulsive paroxysms, 
and of the distribution of the vertebral arteries, much countenances this 
supposition. But in many cases, the excitement seems to be of a more 
direct nature. Strychnia in a poisonous dose excites the medulla so 
speedily, causing tetanic spasm, that its effect can scarcely be due to 
increased flow of blood. So, too, we know, that mechanical irritation 
of the spinal marrow, or of its nerves, will cause convulsive motions ; and 
we find this exemplified in the effect of tumors and spicula of bone in the 
spinal canal, in the head, or in the course of nerves. But nothing ex- 
hibits this element of nervous irritation (apart, so far as is yet known, 
from vascular influence) so fearfully as traumatic tetanus. The irrita- 
tion here begins in a distant nervous branch, and is propagated to the 
medullary centre, the excito-motory function of which at length exhibits 

* Miiller's Physiology (by Baly), p. 737. f Volkman, Muller, p. 738. 

J [Valentin, Carpenter's Human Physiology, p. 296, 3d Am. Ed.] 



83 



ULTIMATE ELEMENTS OF DISEASE. 



a state of erethism, which destroys life either directly by tonic spasm 
(§ 114) of the muscles of respiration, or by exhaustion. Another cause, 
which may be fairly assigned for increase of the involuntary excito-mo- 
tory property, is accumulation by rest. This causes the augmentation 
of this property in the medulla in narcotism from opium, and in injuries 
of the spine (§ 149), which suspend the exhausting influence of volition 
on the whole or part of the marrow, in which, the nervous energy there- 
fore accumulates, and becomes unusually abundant. There is a natural 
increase of this property in sleep, which, by suspending the sensorial 
functions, augments the energy of those of the medulla; and this acces- 
sion of power, which maintains the movements of respiration during 
sleep, also disposes to the occurrence of spasmodic attacks at this time ; 
hence the fits of epilepsy and asthma commonly come on during sleep. 
So likewise sedentary habits, and too much indulgence of sleep, may 
cause an accumulation and morbid excess of involuntary nervous power, 
and develop convulsive and spasmodic symptoms, which are the result 
of its overflow. 

154. Defect of the reflex, or involuntary excito-motory, function is 
exemplified in the paralysis which affects the sphincters, the eyelids, the 
muscles of respiration, and others whose normal action depends on this 
function (§ 148). When this is generally and considerably impaired, 
the result will be fatal, because the respiration, deglutition, and other 
actions essential to life, suffer. It is by affecting these actions that apo- 
plectic coma and narcotism prove fatal ; and the state of sinking from 
excessive weakness or depressing causes, also exhibits the failure of the 
reflex power, when the urine and feces are voided involuntarily, and the 
breathing is irregular and gasping, being forced by voluntary effort. 
From failure of the same power, coughing and expectoration become in- 
efficient in clearing the air passages of mucus; hence the bronchial and 
tracheal rattles which precede death. As these movements are the last 
to fail, so, in recovery from asphyxia, syncope, and other similar states 
of partially suspended animation, the actions connected w T ith the reflex 
function are the first to return with the restoration of life ; and thus vo- 
miting, coughing, and sneezing, are among the early signs of reaction. 

A failure of this function, similar in kind, but less in degree, is ex- 
hibited in all states of extreme debility, whether from excessive fatigue 
or excitement (§§ 64, 65), or from directly depressing or sedative influ- 
ences, as in adynamic fevers (§ 105). A person in this state is too 
weak to sleep; for the medulla partaking of the general exhaustion, can- 
not maintain the respiration without assistance from voluntary efforts. 
Hence the feeling of oppression and the frequent sighing, which banish 
all repose ; or if sleep do occur, it is disturbed by startings and fearful 
dreams, occasioned by the painful sensations of imperfect breathing. 

155. Remedial Measures. — As with other instances of exalted nervous 
function, so with excessive reflex action, when dependent on inflammation, 
or determination or congestion of blood in the medulla, the remedies for 
these are appropriate against this effect; and the same measures in 
smaller degrees are often useful in hysterical affections when these occur 



DISEASED EXCITO-MOTION (REFLEX). 



89 



with fullness of habit, and spinal tenderness. In case of irritation of the 
nervous centres, more purely nervous, as that of tetanus, hydrophobia, 
poisoning with strychnia, &c, a narcotic or sedative, which may lower 
the exalted function, is the desideratum. We possess some agents which 
efficiently reduce the power of the spinal system, and cause general re- 
laxation of the muscles, such as hydrocyanic acid, woorara, Indian hemp 
resin, and conium : these drugs may themselves destroy life by arresting 
the function of the medulla oblongata in maintaining respiration ; but 
this very poisonous action, and the sedative effect which one (hydro- 
cyanic acid) also has on the heart, render the remedy almost as danger- 
ous as the disease.* For slighter irritation of the medulla, however, 
these medicines, in moderate doses, and a few others like them, are often 
beneficial. Thus hydrocyanic acid is a very efficacious remedy in vo- 
miting, nervous palpitation, and hiccup; it is likewise useful in convul- 
sive cough, in which, however, the extracts of belladonna and stramo- 
nium are still more effectual, as they also are in spasmodic asthma. 
The same medicines and opium are often beneficial in relieving the 
spasms of colic, dysentery, and dysuria. 

Some medicines, which act as stimulants to the heart and vessels, and 
to the cerebral functions, seem to operate as sedatives to the medullary 
system: these are the stimulant antispasmodics, such as ether, ammo- 
nia, musk, essential oils, gum resins, creasote, alcohol, &c, which are 
useful remedies in spasmodic and convulsive affections, in w 7 eak sub- 
jects without inflammation; they probably operate by giving vigor and 
equality to the circulation, and by preventing undue determination and 
congestion of blood in the nervous centres. External heat and counter- 
irritation act in a similar way. 

There is another class of remedies which have some power in reducing 
the excitability of the spinal excito-motory system — namely, tonics, es- 
pecially those prepared from metals : but the operation of these is gradual, 
and therefore probably indirect. The sesquioxide and other preparations 
of iron are efficacious in chorea, and perhaps in the more chronic forms 
of tetanus. Nitrate of silver, sulphate and oxide of zinc, and sulphate 
of copper, have been found to diminish the attacks of epilepsy, hysterical 
convulsions, spasmodic asthma and cough, and other convulsive affec- 
tions. The more obvious operation of these affections is on the vascular 
system, to which they prove astringent and tonic, and it is uncertair 
whether their beneficial action in nervous diseases is of this kind only 
equalizing the circulation, or whether; they exercise any more direct in 
fluence on the nervous system. The same question is open with regard 
to certain regiminal means which are effectual in reducing nervous ex- 
citability, such as cold bathing, country air, and change of air, and 
exercise. The latter, however, no doubt may be useful by exhausting 
the superfluous nervous power (§ 153) by another channel, voluntary 
motion. 

The chief remedies to sustain defective or failing medullary function 
are stimulants, narcotics, and various strengthening measures. Thus a 

* From the late accounts of Dr. O'Shaughnessy and others, the resin of the Indian hemp 
seems to be more powerful than any other remedy in relaxing tetanic spasm, and in at leas! 
alleviating the symptoms of hydrophobia. 



90 



ULTIMATE ELEMENTS OF DISEASE. 



fatal state of sinking has sometimes been removed by the free adminis- 
tration of ammonia, ether, brandy, and other stimulants; and the best 
proof of their beneficial operation is when they procure refreshing sleep, 
which in itself is a source of renewed power. Narcotics would also 
seem to be indicated, but in an extreme condition of weakness, their 
indiscriminate employment is hazardous, as they may paralyze the little 
remaining power, and lull the patient into the sleep of death. They 
should be preceded by, or combined with, stimulants ; and those narco- 
tics should be selected which have the least depressing action, such as 
opium. Other means must not be neglected to sustain the power restored 
by stimulants, especially suitable nourishment frequently administered 
in a liquid form. 

REFLECTED OR SYMPATHETIC SENSATIONS. 

156. Clinical observation teaches us that not merely motory impres- 
sions, but those also which cause sensations, may be reflected, so that 
when the impression is made on one part, the sensation is experienced 
in another. I do not allude to the fact that a stroke on the nervous trunk 
produces feelings referred to its branches, but I advert to impressions on 
the ultimate distribution of one nerve producing sensations in parts sup- 
plied by another nerve, or by another branch of the same nerve. The 
following are examples of this kind. Touching the external auditory 
meatus causes a tickling sensation in the glottis. A calculus in the 
bladder produces pain referred to the extremity of the penis. Ascarides 
in the rectum cause itching of the anus, and sometimes of the pudenda. 
Congestion of the liver sometimes is accompanied by pain in the right 
shoulder-blade ; and a disordered state of the stomach, occasionally with 
pain in the left shoulder-blade. The pains of angina and gastrodynia 
often extend to the whole chest, and the former especially radiates to the 
left arm. Severe frontal headache is almost instantly caused in some per- 
sons by acid ingesta, in others by eating ice. Irritation of the intestines, 
as in cholera and colic, (especially painter's colic,) frequently causes 
pain and tenderness in the legs and feet, even when there has been no 
cramp or other excito-motory phenomena. Temporary neuralgic affec- 
tions, generally described as spinal irritation and cutaneous sensibility, 
seem to be due to similar causes. 

In these and other instances that might be cited, the sensations cannot 
be referred to direct nervous communication, but to an influence reflected, 
probably from the spinal centre only. 

The sympathies subsisting between some organs are very remarkable, 
and none more so than between the breasts and the uterus. Applying 
the infant to the breast often induces uterine pains in women recently 
delivered ; and the catamenial discharge has been excited in some in- 
stances by stimulating applications to the breasts. 

157. The remedies most effectual in relieving reflected sensations 
are — 1st, those that remove their irritating cause; and 2d, those that 
deaden sensibility (§ 137), anodynes. The peculiar efficacy of trisnitrate 
of bismuth and hydrocyanic acid in relieving gastrodynia and some kinds 
of angina, is, however, not explicable by any narcotic quality, and is 



DISEASES OF SECRETION. 



91 



probably due to an influence exercised on the power of the nerves to 
transmit sympathetic irritations. These morbid sympathies are often 
exalted in common with other nervous properties (§§ 126, 148), by weak- 
ness or irregularity of the circulation (§ 153); and are generally dimi- 
nished under a tonic plan of treatment, especially with the metallic 
tonics, preparations of iron, nitrate and oxide of silver, sulphate of cop- 
per, arsenic, &c. 



SECTION VI. 

DISEASES OF SECRETION. 

158. The power of secretion appears to be a vital endowment of the 
ultimate cells or molecules of secreting structures.* It is uncertain 
whether the process comprises the formation as well as the separation 
from the blood of the peculiar matter of the secretion. In the case of 
the urine and bile, it would seem that they may be formed in the blood 
without the aid of the secreting organs ; for urea is found in the blood of 
animals whose kidneys have been prevented from acting by ligature of 
their blood-vessels, or by extirpation; and both urea and some of the 
principles of the bile (coloring matter and cholesterine), are found in the 
blood and in various parts of the body when the kidneys and the liver 
respectively have been disabled by disease. But whether the secreting 
structures assist in the formation, or only effect the separation of the 
matters which they eliminate, their elective power is equally a peculiar 
attribute of life, and is at present inexplicable by any physical or che- 
mical law. I have, for the last twenty years, f advocated the opinion 
recently advanced by Dumas and Liebig, that the formation of the prin- 
ciples of the chief secretions takes place through chemical affinities, 
especially those of the absorbed oxygen and the constituents of the blood, 
controlled by vital agencies; but this view leaves still as a vital property 
the power which the liver has to separate bile ; the kidneys, urine ; mucous 
membranes, mucus, &c. 

We are thus led to consider secretion as a peculiar property of the 
secernent structures, just as irritability is of muscular fibre (§ 110); and 
as such its disorder constitutes a primary element of disease. In doing 
this, we avoid the hypothesis of some physiologists, who ascribe secre- 
tion to nervous influence, a notion by no means accordant with nume- 
rous facts. 

159. In reviewing the disorders of other vital properties, we have 
found that many of them are plainly referable to changes in the supply 
of blood to their respective textures (§§ 113, 127, 131, 133, &c). The 
same cause may be found still more decidedly to operate in producing 
variations in the process of secretion. The blood being the material 

* Muller, De Glandularum penitiori structura. Henle, Allgemeine Anatomie. Goodsir, 
Trans. Royal Society of Edinburgh, 1842. Bowman, Phil. Trans., 1842. 

j" In a thesis, De sanguine ejusque mutationibus, Edin., 1824. See also Med. Gaz > September 
and October, 1830. 



92 



ULTIMATE ELEMENTS OF DISEASE. 



from which the secreted matter is supplied, variations in the quantity or 
quality of the blood will surely alter the quantity or quality of this pro- 
duct. Thus when an increased flow of blood takes place to a mucous 
membrane, its secretion is increased, and sometimes rendered more acrid 
than usual; whilst a congested state of the same membrane may im- 
pair the secretion. Hence the most common causes of altered secretion 
are those which operate on the sanguiferous system and its contents. 

160. But affections of the nervous system, and of the mind, which 
acts through that system, may also influence the secreting process, as 
shown by the mouth watering at the sight or thought of a good meal ; 
the bilious diarrhoea that mental agitation will cause in some persons; 
the large flow of limpid urine after nervous agitation; the tears excited 
by grief or other strong emotion ; the unwholesome quality of a nurse's 
milk when she is in a state of anxiety or apprehension. We do not 
know whether these influences act by altering the flow of blood (§ 159), 
or by more directly modifying the vital property of the secreting organ 
(§ 158). 

161. The importance of this element of disease may be estimated, 
from the ubiquity of the process of secretion, which includes both excre- 
mentitious (only to be voided out of the system), and recrementitious pro- 
ducts, (those concerned in digestion, assimilation, and nutrition,) and 
also from the extent of its effects in relation both to the destination of the 
secretion, and to the blood from which it is separated. These may se- 
verally be EXCESSIVE, DEFECTIVE, AND PERVERTED. 

162. Excessive secretion of any kind , whether bile, urine, mucus, 
&c, may weaken by the drain which it causes from the mass of blood 
(§§ 28, 71); and this effect will be in proportion to its quantity, and es- 
pecially to the animal matter which it contains. Thus an excessive se- 
cretion of bile weakens more than that of thin mucus. But each secre- 
tion may have peculiar effects connected with its office and composition; 
and these effects may be forwards, on the parts to which the secretion 
goes, and backwards, on the organ which secretes it, and on the blood 
from which it is formed. 

163. The forward effects of an excessive secretion of bile depend 
on its stimulating properties. It irritates the intestinal tube, causing a 
bilious diarrhoea or cholera. The symptoms of this consist in an ex- 
aggeration of those properties of the alimentary canal which have al- 
ready been described as elements of disease. Thus the bile irritating 
causes increased irritability (§ 113), and more rapid motion of the mat- 
ter through the tube; pain from exalted sensibility (§§ 134, 135); vo- 
miting, straining, and cramps, from exalted excito-motory function (§§ 149, 
151); profuse mucous secretion from excited secernent function (§ 162). 
An excessive secretion of mucus in the intestines may cause only simple 
diarrhoea; but in the bronchi it may occasion dyspnoea and cough, and, 
if not expectorated, may suffocate. Excessive secretion in the stomach 
may cause pyrosis or waterbrash, the liquid being sometimes acrid, and 
may occasion nausea and vomiting, as w T ell as eructation. The exces- 
sive discharges from secreting organs generally may amount to a flux or 
profluvium ; and those from internal enclosed serous surfaces or cellular 



EXCESSIVE SECRETION. 



93 



texture, constitute various dropsies. These produce different effects ac- 
cording to their situation. 

164. But excessive secretion may also have effects backwards, on the 
organs, and on the blood from which it proceeds. Excessive secretion 
often weakens the vital properties of the organ, so that, in its proper 
function, it subsequently becomes torpid. Thus after diarrhoea, the 
bowels often become torpid from defective secretion. So, too, in cases 
where an excessive secretion continues for a long time, it generally is 
impaired in its quality from a similar cause. 

165. Excessive secretions, if abounding in animal matter, may not 
only reduce the mass of the blood, but also affect its composition. Thus 
bile and urine, which differ much in composition from the blood, if 
separated in unusual proportions, must leave the blood modified. Urine 
contains a great preponderance of azote; and its excessive formation 
from the principles of the blood w r ould leave a predominance of hydro- 
gen and carbon in this fluid. The bile, again, abounds in hydrocarbon, 
the copious removal of which would leave a superfluity of azote. It 
may be objected to this statement, that, according to the opinion of some 
chemists, the urine and the bile are not formed from the constant elements 
of the blood, but from materials derived from the food, and from the de- 
cay or transformation of the tissues. To this it may be replied, that this 
opinion is at present no more than hypothetical ; and should it prove to 
be true, it would not affect the undoubted fact, that the secretions of the 
liver and of the kidneys are intended to balance one another, and the 
removal of carbon from the lungs ; and that whether the materials from 
which these eliminating processes are supplied, be the principles of the 
blood itself, or the decayed constituents of tissues, or matters derived 
from the food, the co-operation of all these processes will be generally 
required to maintain a uniformity in the composition of the circulating 
fluid; so, too, if one of these processes is more active than the others, 
the blood must suffer by the excess of those matters which the less active 
processes allow to accumulate in it(§§ 68, 69). A clinical illustration 
of this position may be found in cases of bilious diarrhoea or cholera. 
This flux of bile is either accompanied by a highly loaded state of the 
urine, or by fever; in the latter case, the fever does not subside until 
the urine becomes very copious, or deposits an abundant sediment. The 
most probable interpretation of this fact is, that the excessive secretion 
of bile disorders the composition of the blood ; so long as the kidneys 
rectify this disorder by separating in greater abundance the solid contents 
of the urine, no fever results; but if the kidneys fail in this task, fever 
ensues, and continues until they accomplish it ; then a free secretion 
and copious deposit are symptomatic of the decline of the fever. 

166. The remedial measures that are serviceable in cases of excessive 
, secretion, well illustrate the view that has just been given of the balanc- 
ing office which the secretions all fulfil. In so far as excessive secretion 
is dependent on the quantity and quality of the blood (§ 159), the treat- 
ment should be addressed to this element: by depletion, derivation, and 
evacuation, in cases of congestion or determination of blood : and in 
such cases, the excessive secretion should not be hastily checked, as it 



94 



ULTIMATE ELEMENTS OF DISEASE. 



may be a natural means of relief; nay, in some cases, it may be most 
speedily arrested by means which for the time increase it : thus a large 
dose of calomel will sometimes, after first purging, stop a bilious diarrhoea 
connected with an engorged liver, which astringents fail to check. But 
where the excessive secretion proceeds more from nervous and other 
sources of irritation (§ 160), and causes weakness and disturbance of the 
functions, it becomes a more immediate indication to check it. Secre- 
tions are to be diminished by means which act as general tonics or as- 
tringents (§ 124), and by others which operate only on particular organs. 
Of the former class are cold applied to the part, and common astringents, 
such as alum, superacetate of lead, sulphates of zinc and copper, gallic 
acid and tannin, and substances which contain them, as nutgalls, oak 
bark, rhatany root, catechu, &c, mineral acids, &c. These act most 
surely by direct application, as in their use for diarrhoea, leucorrhoea, 
&c. ; but they seem to have some effect also through the medium of the 
circulation, as when taken internally, they reduce the secretion in the 
air-passages and skin. Of the agents which, without a general astringent 
effect, more specifically diminish the secretion of particular organs, may 
be mentioned opium, w T hich remarkably lessens the secretion of the liver, 
and sometimes that of the kidneys. 

If an excessive secretion have already caused febrile disturbance, great 
advantage will be found to result from the use of means which increase 
other secretions, and thus restore the balance before explained (§ 165). 
Thus in bilious cholera, saline diuretics and diaphoretics are highly ser- 
viceable. In renal irritation, with copious secretion of lithic acid, blue 
pill, which augments the secretion of bile, is often beneficial. These 
means may be supposed to operate partly as derivants; but the manner 
in which they remove the febrile irritation, after the reduction of the ex- 
cessive secretion, renders it most probable that they act also by remov- 
ing from the blood dregs left by the inordinate separation of the matter 
of the single secretion which has been in excess (§ 165). No practical 
physician can doubt that we possess medicines which often augment the 
secretions of particular organs, (mercury that of the liver, and salivary 
glands, colchicum that of the kidneys, &c.,) yet there is a limit to the 
operation of these agents ; but this limit may be increased by simulta- 
neously acting on other organs which maintain the balance. Thus in 
any disturbance of the secretions, especially if it continue long, combi- 
nations of medicines are much more useful than those fulfilling one indi- 
cation only; and thus experience has sanctioned the practice of conjoin- 
ing mercurials with diuretics, and antimonials with salines, &c. 

167. Secretions may become defective in consequence of a weak- 
ened state of the whole circulation, or of that of the secreting organ, as 
in the case of exhaustion from previous excitement (§ 164). Or they 
may be impaired by depressing influences which paralyze the vital 
powers, as in the case of morbid and narcotic poisons (§§ 56, 64, 65); 
or they may be checked by agents which increase the tonic contraction 
of the vessels of the part, as cold (§ 77) and astringents, or of the whole 
sanguiferous system, as in the case of the hot stage of fevers (§§ 85, 421). 

Defective secretion of any natural or habitual discharge (§ 70), may 



DEFECTIVE SECRETION. 



95 



cause a fullness of the blood-vessels: a general fullness, if the secretion 
be naturally copious ; a local fullness, if it be trifling in quantity. Thus 
defective secretion of urine or bile may cause general plethora, or ex- 
tensive local congestions, which may end in dropsical effusions, fluxes, 
hemorrhages, or inflammations. Diminished secretion of tears or sa- 
liva would merely cause fullness and dryness of the parts immediately 
concerned. 

The morbid effects of defective secretion may be both forwards, on the 
parts for which the secretion is intended, and backwards, on the organ 
and on the blood from which it should be eliminated (§ 162). 

168. Defective secretion of bile causes disorder in the latter stages of 
digestion. The neutralization of the acid in the chyme, and the separa- 
tion of the chyle, to which the bile seems to contribute, are imperfectly 
performed: sometimes colic and diarrhoea, sometimes costiveness, result 
from the defect. Deficient secretion of mucus in the intestinal canal and 
bladder would expose their membranes to more irritation from their con- 
tents. Probably deficient secretion of mucus on the respiratory mem- 
brane may lessen the facility with which the air and the blood act on 
each other. Insufficient secretion of cerumen in the ear, or of saliva in 
the mouth, impairs respectively the hearing and the process of mastica- 
tion. A want of synovia in the joints, has been supposed to be a cause 
of their imperfect motion and subsequent inflammation. 

169. The effect of defective secretion in causing congestion of its re- 
spective organ, has been already noticed : the concomitance of conges- 
tion with defective secretion, in the case of the liver, the kidneys, and 
mucous membranes, is well known ; but either may be viewed in the 
light of both cause and effect. 

170. The most remarkable of the backward effects of defective se- 
cretion are instanced in case of the excretions (§ 70). The distinctive 
materials of the secretions of urine and bile appear to be positively 
noxious, and poison the system if not separated from the blood. Thus 
the sudden suppression of urine or bile causes typhoid symptoms, ex- 
treme depression, and coma, which speedily end in death; and in such 
cases, urea, or the coloring matter of the bile, has been found in various 
organs. Where the suppression is incomplete, the poisoning process is 
more tardy : various functional and visceral derangements are produced, 
such as delirium, or lethargy, dyspnoea, palpitation, vomiting, diarrhoea, 
dropsical effusions, structural degenerations, &c, which always cause 
injurious effects, if the defective excretion be not restored. But the 
amount of these effects will depend on the extent, and especially on the 
suddenness, of the diminution of the excretion ; and it is very remark- 
able when it is very gradual, how little disturbance it may for some time 
induce. In these gradual cases, still more remarkably than in those of 
more sudden suppression, some of the excrementitious matters may be 
detected in the blood and in other fluids and solids of the body. Thus 
in some structural diseases of the liver, the color of the bile becomes 
manifest, first in a yellow, and by accumulating, in a deep greenish 
color in all the textures, constituting the yellow and the black jaundice. 
In granular degeneration of the kidneys, in which scarcely any urea is 
excreted by these glands, this principle is found in the blood and various 



96 



ULTIMATE ELEMENTS OF DISEASE. 



fluids of the body. In the case of a patient of mine, affected with as- 
cites from disease of the heart, liver, and kidneys, Mr. Garrod obtained 
nearly four grains of nitrate of urea from an ounce of the peritoneal 
fluid, and a considerable quantity of bright yellow solid matter, probably 
bilious. In other cases, I have known the fluid of ascites and anasarca 
from diseased kidneys, emit a decidedly urinous smell, and exhibit on 
analysis easily appreciable quantities of urea. One of my pupils, Mr. 
Palmer, detected urea in the serum contained in the ventricles of the 
brain, in a case of fatal apoplexy from granular kidneys and diseased 
heart. 

171. The excretions are defective in many idiopathic and symptoma- 
tic fevers; and there can be little doubt that many of the constitutional 
effects of these fevers are in great measure due to this important element. 
The positively noxious properties which excrementitious matter retained 
in the blood is known to possess (§ 170), must be taken into account 
when we attempt to explain the states of constitutional irritation and de- 
pression, with perversion of functions, which fevers so generally present. 
[One of the most interesting facts connected with the pathology of the 
epidemic fever which prevailed in Edinburgh in 1843, was the discovery 
of urea in the blood and serous fluid of the ventricles of the brain, in 
some of the patients affected with cerebral symptoms. " The existence 
of urea in the blood," says Mr. M. W. Taylor, (Scottish Med. Gaz., p. 
281,) " in other cases, has been inferred from the occurrence of disor- 
ders of the nervous centres, which we know to be the consequence of its 
undue accumulation in the circulation. These phenomena have been 
observed in those cases in which, from some cause or other, the daily 
discharge of urine has undergone material diminution."* — C] The 
changes in the blood, manifest in some such cases by its fluidity and by 
petechial appearances, may also be in part referred to defective elimina- 
tion of effete matter;! and it is when the secreting organs recover their 
power, and a diarrhoea occurs, or a copious discharge of highly loaded 
urine, that these appearances cease. It is very probable that severe 
mechanical injuries or shocks (§ 52), and animal and other poisons (§§ 
85, 105, 57, &c. ), operate by thus injuring the vital powers by which 
the blood is continually purified from its own noxious products ; and that 
this is a part of their mode of action, seems almost certain from their ef- 
fect in suppressing or impairing the natural excretions. Accordingly, 
in such cases, urea has sometimes been detected in the blood. 

There can be little doubt that a morbid element, which in its extremes 
acts so injuriously as to cause serious disorder, and even speedy death, 
must in slighter degrees be an important cause and constituent of dis- 
ease; and I believe that gout, rheumatism, and many cachectic states 
leading to diseases of nutrition, degenerations, dropsies, &c, are essen- 
tially connected with defective excretion. 

172. Remedial Measures. — Defective secretion may be caused by 
deficient or excessive supply of blood to the part, as in various cases of 

* [Clyraer on Fevers, p. 92, Phil., 1846.— C] 

t Purpura I have found to be often connected with hepatic congestion, and imperfect 
excretion of bile, and to be most effectually removed by remedies which promote the re- 
storation of the proper secretion. 



DEFECTIVE SECRETION. 



97 



anaemia, congestion, and inflammation (§ 159). In such cases it must 
be treated by the proper remedies for these conditions : thus stimulants 
may restore secretions scanty through a defective supply of blood ; and 
depletion and derivation may be the best remedies, when they are stop- 
ped by inflammation or congestion. 

173. But sometimes the first disorder is in the secreting structure it- 
self (§ 158), and may best be removed by agents which specially in- 
crease the respective secretions, which common stimulants will not do. 
Thus mercury increases the secretion of the liver ; colchicum, nitre, and 
other diuretics, that of the kidneys ; croton oil, jalap, sulphate of magne- 
sia, and other purgatives, that of the intestines ; and this they do, how- 
ever introduced into the system, whether by the mouth, through the skin, 
or injected into vessels or textures. These are important practical facts, 
however difficult they maybe to explain ; and their application to restore 
defective secretions is abundantly obvious. 

174. But these specific stimuli of the secreting organs (§ 173), if used 
in excess, or too long, may not only cause general weakness, but also 
exhaust the vital properties which they excite (§ 159); and the result 
may be a diminution either of the secreted fluid, or of its most character- 
istic constituents. Hence the long or excessive use of mercury causes 
torpidity of the liver ; that of purgatives, imperfect action of the bowels; 
that of diuretics, scanty urine, or albuminous or watery urine, defective 
in urea. These facts point out the expediency of intermitting the use of 
these agents, and of alternating or conjoining them with others calcu- 
lated to improve the vital properties of the textures generally, which may 
often be effected by the medicines called tonic, and by regiminal means 
which improve and equalize the state of the circulation (§ 124), and pre- 
serve the digestive and assimilative functions in the best order. In illus- 
tration of this position, I may refer to the acknowledged advantage of 
giving bitters with or after mercurial courses ; chalybeates with or after 
saline aperients and diuretics, when these are long used ; and these ad- 
ditions, which alone, or used at first, would check the secretion to be in- 
creased, now sustain it and render it permanent. Some medicines which 
are inferior in efficacy to those already named, are yet, in some instances, 
more eligible for chronic cases of defective secretion; because they 
are less exhausting, and combine some measure of tonic influence with 
that of increasing the secretions. As examples of this kind may be 
named taraxacum, preparations of iodine, sarsaparilla, nitric, and nitro- 
muriatic acids. Courses of these medicines are sometimes of great effi- 
cacy in keeping free the secretions after they have been restored by more 
powerful means (§ 173) ; and they likewise often improve the functions 
of digestion and nutrition. 

175. Where defective secretions are not readily restored, the forward 
disorder (§ 168) arising from their deficiency, may be sometimes com- 
pensated by artificial substitutes. Thus, in defective secretion of bile, 
the action of the intestines has been promoted by exhibiting ox gall. 
Aloes and soap combined have been thought to supply the place of bile 
in some cases. Toasted bacon at breakfast has been supposed to have 
a similar effect ; but it more probably excites the liver to increased 
secretion, as other fat matters do. Imperfect lubrication of the throat and 



98 



ULTIMATE ELEMENTS OF DISEASE. 



larynx, and other mucous membranes, from defect of mucus, may be 
remedied by mucilaginous and demulcent matters. A dry state of the 
skin may be relieved by applications of oil or honey. 

176. Perversion of secretion often accompanies excess and defect 
of this process. In febrile diseases, the secretions of the kidneys and 
alimentary canal are altered as well as diminished. Inflammation and 
determination of blood change as well as increase the secretion from 
mucous membranes, rendering it more saline, and sometimes albuminous. 
The urine exhibits remarkable changes in quality: full living, stimulating 
beverages, and irritations of the digestive organs or kidneys, rendering 
it unusually strong and acid; whilst low diet, and other causes of weak- 
ness, generally make it pale and alkaline. Out of these morbid con- 
ditions may arise various further decompositions, with sediments and 
calculous concretions of different kinds (§§ 51, 53). Concretions are 
likewise formed from an altered state of the bile. The alvine secretions 
are greatly modified by various febrile and cachectic diseases, being altered 
in color, and unusually offensive in odor. The perspiration is also some- 
times changed ; thus it is very acid in rheumatism, and fetid in delirium 
tremens. 

177. Secretions which serve particular purposes, when altered may 
become unfit for these, and thus cause disorder: thus a thin acrid mucus 
irritates, instead of protecting, the membrane which secretes it, as in 
coryza and mucous diarrhoea ; a viscid dry mucus clogs up and obstructs 
tubes which it was intended to lubricate; altered gastric juice causes 
indigestion; sebaceous matter of the skin may accumulate in its follicles, 
and cause irritation and inflammation, &c. 

178. The remedies for perverted secretions (§ 176) are usually those 
which likewise increase secretion (§§ 172, 173). Thus depraved secre- 
tions of the intestinal canal are often satisfactorily altered by continued 
purging; a turbid state of the urine is sometimes removed by diuretics; 
too thick a state of the mucus of the air-passages is modified by expec- 
torants, &c. But where the change depends on altered circulation in 
the part, the remedies must be suited accordingly. In some cases, tonics 
restore a healthy state of secretions; and in most instances of long-con- 
tinued perversion, tonics may be advantageously combined with medi- 
cines which increase secretion (§ 174). Such a combination is presented 
in most of those remedial agents which have obtained the appellation of 
alteratives, and which would seem to be especially suited to oppose the 
diseased element under consideration, if they really possessed the virtues 
ascribed to them. 

Nutrition is also effected by the property of secretion (§ 158); but 
inasmuch as its changes cannot be understood without a previous know- 
ledge of the blood and its constituents, and involve the complex subject 
of structural disease, their consideration will be deferred. 



ELEMENTARY CHANGES OF THE BLOOD. 



99 



SECTION VII. 



DISEASES OF THE CONSTITUENTS OF THE BLOOD. 



179. The pathological elements (§ 107) which we have hitherto con- 
sidered, are those of the vital properties of the elementary solids. We 
now proceed to examine the morbid changes of the blood. These, like 
those of the solids, may be often traced to individual elements, of which 
the blood is composed, the changes of which must be viewed as ultimate 
elements of disease, and are therefore properly included in the present 
division. But as the blood also operates as a whole, compound indeed 
in itself, but simple in its influence, on vital functions and structures, it 
forms a proper connecting link between ultimate and proximate elements 
of disease. So, also, inasmuch as it is, in some respects, an organized 
compound, the materials of which are changed, together with its func- 
tions, and contributes to the production of change of structure in the 
solids of the body, the consideration of its changes will be a proper in- 
troduction to that of alterations in the circulation, which induce change 
of structure, and thus lead to structural diseases themselves. 

180. We have found that blood is the support of all the vital proper- 
ties ; and in describing their variations, we have been obliged to refer 
frequently to differences in the supply or quality of this fluid, both as 
causes and as consequences of these variations, (§§ 113, 127, 131, 159, 
&c.) We have now to examine the properties of the blood itself, and, 
first, those which are most elementary, or referable to its respective con- 
stituents. 

The circulating blood consists of red particles, colorless globules, and 
liquor sanguinis : but as the latter is compound in function as well as in 
constitution, it is necessary to specify its chief constituents. We have, 
then, to consider — 

1. The red particles, 

2. Fibrin and colorless globules, 

3. Albumen and other dissolved 
animal matters, 

4. Oil, 

5. Salts, 

6. Water, 

181. The average natural proportions of the chief constituents of the 
blood, according to Lecanu, and adopted by Andral and Gavarret as a 
standard, are 127 red globules; 3 fibrin; 72 animal matter in the serum; 
8 salts ; 790 water.* 

RED PARTICLES. 

182. The red blood-discs appear to be the part of the blood on which 

* Annales de Chimie et Physique, Nov. 1840, p. 229. 



■ in excess, defect, and 
alteration. 



100 



ULTIMATE ELEMENTS OF DISEASE. 



its vivifying and calorific properties chiefly depend. Thus Prevost and 
Dumas found that animals bled almost to death could be restored by in- 
jecting into their veins a mixture of red particles and serum, even when 
the fibrin had been removed ; yet the serum alone failed to produce any 
such effect. It is therefore to be supposed that the red particles are the 
part of the blood required in transfusion in cases of hemorrhage. An- 
dral, Gavarret, and Delafond, remarked that, in domestic animals, the 
vigor and beauty of the animal were proportioned more to the amount 
of red particles in the blood of the animal than to any other constituent; 
and that improvement of a breed by crossing was marked by an increased 
proportion of this element.* The red particles are supposed, by Liebig, 
to be the means by which oxygen is carried throughout the circulation, 
and brought to act on the various textures. Their proportion varies 
considerably in health; in men, it may be stated generally at from 120 
to 140 in 1000 of blood; in females, it is usually from 10 to 20 less. 
They are most abundant in early adult age, and are in rather smaller 
proportions at earlier, and later periods. In the foetus, however, they 
exceed the amount in the maternal blood (in the proportion of 222 to 
140, Denis), and this preponderance is retained for some w r eeks after 
birth, until, in fact, the blood becomes more watery. 

183. Excess of the red particles might, therefore, be expected to cause 
a general excitement of the vital properties of the body(§ 183). Ac- 
cordingly, Lecanu found that they exist in larger proportion in persons 
of sanguine temperament (§ 38), than in others, and especially in those 
of vigorous constitution. Andral and Gavarret detected a slight increase 
of them in some cases of the early stage of inflammations and fevers, 
especially eruptive fevers, as measles and scarlatina. In sanguineous 
plethora, and in hemorrhagic diseases before much blood is lost, they 
were in excess, in some instances rising to 185 in 1000 of blood. The 
obvious sign of the abundance of red particles is the florid color appa- 
rent in the lips, cheeks, gums, and other vascular parts; the deep blue 
color of the superficial veins ; and the fine deep crimson which a thin 
film of blood gives on a white plate. The bodily functions, animal heat 
and muscular irritability are in an exalted state, bordering on or passing 
into febrile excitement. Judging by these indications, w T e may often pre- 
dicate the existence of an excess of red corpuscles in those accustomed 
to good living, with such an amount of exercise in the open air as suffices 
to keep the digestive and assimilative functions in an active state. 

185. The red particles are defective in persons of the lymphatic or 
leucophlegmatic temperament (§ 40) ; after great losses of blood (artificial 
or from disease); in chlorosis, and in other anemic states, as those c*on* 
nected with advanced stages of cancer, diabetes, scurvy, and other ca- 
chectic diseases ; in scrofulous and tuberculous diseases; in the latter 
periods of fevers, and after severe inflammations; in granular degenera- 
tion of the kidney, and other organic diseases, especially when attended 
with dropsy; in diseases of the spleen, and others of malarious origin 
(§ 85); in cases of slow poisoning with lead; and in persons inhabiting 
dark and ill-ventilated abodes. In an extreme case of chlorosis, the pro- 



* Annates de Chimie et Physique, Juillet, 1842. 



ELEMENTARY CHANGES IN THE BLOOD RED PARTICLES. 



101 



portion of the red particles was found by Andral, reduced to 27 in 1000 
of blood. 

The signs of the defect are, paleness of parts naturally colored with 
blood, pallid or sallow hue of the skin, pink color of superficial veins, 
and a pinkish or light purplish hue of a film of blood on white plate. 
The symptoms of such a condition are those which will be more fully 
described under the head of anaemia; a weak state of the functions ge- 
nerally, of circulation, calorification, digestion and nutrition, constituting 
their summary. 

[The maximum attained by the red corpuscles in health is 140, 
whilst the minimum is 110 in 1000. Force and strength of constitution 
are the condition of the economy favorable to the former, and feeble- 
ness, congenital or acquired, to the latter. Sanguine losses, and de- 
privation of food, produce, as a constant effect, diminution in the red 
corpuscles, whilst the fibrin, as we shall see, is less constantly and ne- 
cessarily influenced by these causes. Diminution in the quantity of the 
red corpuscles may exist as an independent morbid state, or may super- 
vene as an epiphenomenon in other diseases. In 24 cases of confirmed 
spontaneous anaemia, the mean of the red corpuscles was 64, (Andral.) 
In the cachectic condition resulting from the poison of lead, so well de- 
scribed by Dr. Tanquerel, the red corpuscles fell to the same mean as 
in spontaneous anaemia, whilst the other materials of the blood remained 
unaltered. Certain modifications in the organism may influence the 
blood, and diminish the quantity of the red corpuscles. This occurs or- 
dinarily in pregnancy. In the neuroses, the blood is remarkably poor 
in red corpuscles; in phthisis, there is diminution of this constituent, as 
well as in all chronic organic diseases. — C] 

186. Alterations of the red particles are evinced by changes in the 
color of the blood, and in the form of the individual corpuscles, as seen 
by the microscope. The coloring matter is evidently altered in some 
diseases, being much darker than usual, as in the worst forms of scurvy, 
in which the blood is said, by Mead, to be changed to a dark-brown or 
green color: in the Walcheren and other malignant fevers, it has been 
described as pitchy black. In the worst forms of cachexia (or rather 
cachsemia), from malarious influence, generally in conjunction with 
disease of the spleen, the blood is not only very poor, but perverted, 
exhibiting various shades of purple, brown and even greenish colors. 
Some change seems to occur in congestive typhoid fevers, in which the 
blood-vessels become stained or dyed of a deep claret color: this imbi- 
bition implies a breaking up and unnatural solution of the red particles. 
Probably the occurrence of petechias and ecchymosed patches in these 
diseases is partly dependent on a similar change. The readiness with 
which the textures become stained in scorbutus, in jaundice, and albu- 
minuria, and in secondary syphilis, seems to indicate an alteration in 
the coloring matter; inflammations and ecchymoses in the skin being 
commonly followed by livid, purple, or copper-colored stains. The yel- 
low tinge of the skin in yellow fever, occurring chiefly along the course 
of the chief blood-vessels, the peculiar sallowness connected with dis- 
eased spleen and in chlorosis, and the dark discoloration around the eyes 
in the same diseases, apparently proceed from a change in the coloring 
matter of the blood, which causes it to escape from the vessels and tinge 



102 



ULTIMATE ELEMENTS OF DISEASE. 



the skin like in a part discolored by a bruise. The black matter of me- 
lanosis seems to be derived from the coloring part of the blood in an 
altered state: this is certainly true of the spurious melanosis of the intes- 
tines. 

187. Besides changes manifest in the color of the blood, the red par- 
ticles are subject to alterations in their form, size, and other properties 
in connection with the medium in which they are placed. It was first 
observed by Hewson,that pure water causes them to swell, become glob- 
ular, and burst ; whilst saline solutions, containing more salts than serum 
does, make them shrink in size. These changes are now generally 
understood to arise from endosmosis and exosmosis : the saline matter 
drawing the water into or out of the little cell, which, with its contained 
coloring matter, constitutes the red particle. It is highly probable that 
similar changes may take place in the living body, from circumstances 
which greatly alter the proportion of saline matter and water in the blood. 
May such change contribute to produce the serious symptoms, and even 
sudden death, which have ensued on drinking a large quantity of water 
after great exertion? Has it aught to do with the reaction and irregular 
excitement sometimes occurring after excessive losses of blood? Or with 
the symptoms of suffering which animals manifest at the instant of in- 
jecting water into their veins? Dr. Owen Rees has suggested that the 
remarkable diminution of the blood discs in cases of albuminuria, may 
be due to their destruction, in consequence of the draining away of albu- 
men from the blood, and thus reducing it to a very watery state; and 
the same circumstance may prevent their re-development from the chyle 
and lymph both in these cases and in chlorosis. In several cases of 
Bright's disease of the kidney, I have observed the blood discs jagged or 
crenate at their margins, and otherwise imperfect ; and the same remark 
has been made by Simon of Berlin and others, and by Andral in a case of 
chlorosis.* In one fearfully rapid example of albuminuria, which proved 
fatal in six days, with effusion of pus in the joints the day before death, 
I found the coloring matter dissolved in the blood-liquor after death, and 
scarcely any red discs remaining. There were numerous pus globules 
in the blood. A similar total destruction of the blood discs was observed 
in University College Hospital, in the blood of a person who died of ma- 
lignant scarlet fever with purpura. I have met with similar proofs of 
breaking up of the red particles, but to a much smaller extent, in acute 
purpura connected with jaundice, and in cases of disturbed function of 
the liver without jaundice: is this due to the remarkable solvent power 
exercised by small proportions of bile on the red particles, noticed by 
Simon and others? 

* [In two cases of chlorosis, Andral found the red corpuscles smaller than usual, and many 
of them altered in form, appearing in the field of the microscope, as if broken into fragments. 
A young girl whose blood presented this appearance, became, after two months of appro- 
priate treatment, plethoric; and, at this interval, on the globules being examined, they were 
found in a perfectly healthy state. In an epidemic typhus which prevailed in different dis- 
tricts of Italy, in 1841, M. Renzi of Naples, states, that the red corpuscles were readily freed 
of their coloring matter, seemed to have lost their central nucleus, and were altogether less 
compact and solid than naturally. In the Edinburgh epidemic fever of 1843, on examining 
the blood of a number of patients, Prof. Allen Thompson and Dr. Cormack found the red 
corpuscles serrated and notched (a) — C] 



(a) Clymer on Fevers, p. 91, Phil, 1846. 



ELEMENTARY CHANGES IN THE BLOOD — RED PARTICLES. 103 

188. The change of the blood from dark to florid, on the addition of 
saline matter, appears to depend on the increased density and distinct- 
ness given to the red particles, and to the colorless globules, whereby 
they reflect light more abundantly, and are also rendered less transpa- 
rent.* Probably the action of oxygen in reddening venous blood, is of a 
similar character, for it also renders the blood less transparent. This 
explanation of the color of arterial blood was suggested to me by some 
experiments which I made in 1835, and in some measure corresponds 
with the opinion of Dr. Wells, f that the brighter color is due to fine me- 
chanical division. Dr. J. Davy, in 1838, expresses a like conclusion. 
More recently Mulder's notion, that the florid color of the arterial blood 
is caused by the formation of a film of solid deutoxyde of protein on each 
particle, implies a similar explanation of the physical cause of the bright 
color, which he further shows not to depend on any change in the color- 
ing matter itself ; but his explanation will not apply to the more rapid 
and complete brightening of blood by saline matter. I have noticed that 
the dark fluid blood found in the body in malignant scarlatina, and other 
bad congestive fevers, does not redden so soon as usual on exposure to 
the air. The same remark applies to some of the cases of altered red 
particles mentioned above (§ 187). 

189. The red particles are distinct structures, living cells, or celliform 
nuclei (Wharton Jones), although isolated, and floating in a lifeless fluid. 
Like other living cells, they probably possess the power of secretion ; 
but what they secrete, whether fibrin or the peculiar principles of the ex- 
cretions, has not been ascertained, and we can, therefore, say nothing of 
their modifications. It has been conjectured that they have other vital 
properties, such as spontaneous motion, and attractions and repulsions ; 
but there are no unequivocal facts in support of such notions. The mo- 
tions described by Treviranus, Schultz, and others, may be accounted 
for on purely physical principles. It is said, that a systolic and diastolic 
movement in blood particles has been observed by Dr. Martin Barry in 
the Fallopian tube of a recently impregnated rabbit; but this seems to 
have been an effect of the movements of the cilia of the membrane. 

190. Hewson, Prevost, Dumas, and others, observed that the red par- 
ticles of new-drawn blood cohere together in piles or rouleaus. This co- 
hesion in healthy blood is of very short duration : for it has been remarked 
by Dr. Hermann Nasse and Mr. Wharton Jones, that in a few seconds, 
the discs may be seen loose and confused ; but in blood drawn from a 
person affected with inflammation, the cohesion takes place earlier, is 
more firm, and lasts longer than usual ; and they consider this the chief 
cause of the separation of the red particles from the fibrin, which consti- 
tutes the buffy coat. We shall notice the relation of this phenomenon to 
the buffy coat under the head of fibrin ; but of the cohesion of the red 
particles, we would remark, that it is not certain that it is more than one 
of mechanical aggregation modified by changes in the relative dilution 
of the liquor sanguinis, without and within the blood corpuscle. The 
even momentary exposure of so thin a film of blood to the air causes 
evaporation, which affects the serum before it can reach the interior of 



* Medical Gazette, Sept. 1835. 



t Phil. Trans., 1795. 



104 



ULTIMATE ELEMENTS OF DISEASE. 



the blood particles. At this time, they cohere ; but the exosmosis pro- 
ceeding from the individual particles, soon again detaches them from 
each other.* But, without dwelling on this or the equally hypothetical 
notion that the cohesion is due to a vital attraction, it is not unimportant 
to observe this property, and the variety which is presented in inflamma- 
tory disease. It has been supposed that a similar aggregation of the 
blood corpuscles occurs within the blood-vessels, and is the cause of ob- 
struction in the capillaries in inflammation and other cases of impeded 
circulation. But no regular or firm cohesion is seen in the large vessels 
of a frog's web, when the motion of the blood is arrested by pressure on 
a vein ; and although the blood-discs do accumulate and cohere in some 
of the vessels of an inflamed part, this will be hereafter shown to be due 
to an obstruction by the colorless particles. (See Inflammation.) 

191. There is still much doubt with regard to the origin of the red 
particles ; and there is a corresponding uncertainty as to the essential 
seat and mode of their increase. It is most probable that their develop- 
ment and growth, as well as their decay, take place throughout the san- 
guineous system, but are most favored by the changes to which they are 
exposed in the great depurative organs, the lungs, liver, and other glands. 
Whether they originate in the organic globules of the chyle and lymph, 
or from the granules of the white corpuscles, or from both, is quite un- 
determined; but such an origin appears more in accordance with ob- 
served facts than their supposed multiplication by the division of the old 
discs. Their increase is intimately connected with an active state of the 
organs concerned in general nutrition, especially where their formation 
is favored by a supply of the ferruginous material which forms a dis- 
tinctive feature in their composition. 

The influences which promote the decay and retard the formation of 
the red particles (§§ 185, 186), are chiefly those which impair the nutri- 
tion of the body; but there are some which affect the red particles much 
more than they do other components of the body. Two of the most re- 
markable are a diseased state of the spleen, and disordered uterine func- 
tion. The striking pallidity, or pale sallow hue of persons who have 
been long suffering from malarious influence, more particularly in warm 
climates, has often attracted attention; but it is now generally considered 
that these are cases in which the spleen has become diseased, an ac- 
knowledged result of the continued operation of malaria. The state of 

* Hence, as it has been remarked by Mr. Gulliver, the addition of a little salt prevents 
the cohesion of blood-discs. I do not assert that there is nothing vital in these properties 
exhibited by the organized parts of the circulating fluid, but I must protest against the hasty 
assumption made by some physiologists, that the motions and alterations revealed in animal 
and vegetable fluids by the microscope, are all dependent on a mysterious vitality. If any 
microscopical observer will take the trouble to watch the behavior of any light flaky preci- 
pitate recently thrown down from a solution in water or spirit, he will see motions and ag- 
gregations as remarkable as those of the recently effused blood-discs, although less regular 
from the unequal size and shape of the particles. The close and orderly arrangement of 
the blood-discs is favored by their mobility and flatness, which facilitate the operation of the 
aggregative force; and in this respect, they contrast with the white globules, whose globular 
shape and larger mass render them less apt to coalesce ; they, however, often form centres, 
around which rolls of discs cluster in circles or rays. It is remarked by Mr. Gulliver, that 
the elliptical particles of reptiles and camels cohere together in irregular heaps, without the 
rouleau arrangement seen in the round discs, which is therefore the more probably due to 
their mechanical properties. 



ELEMENTARY CHANGES IN THE BLOOD — RED PARTICLES. 



105 



the blood in these affections has been noticed (§ 186); and it maybe 
further explained that a diseased spleen operates not only by withdraw- 
ing from the circulation an undue proportion of blood, but, by keeping it 
in a stagnant state, unrenewed and unpurified by the processes of cir- 
culation and excretion, it spoils the blood, and renders it unfit for further 
use. Hence, when in lapse of time, and under changes of circulation 
wdien portions of this spoilt blood are again rendered into the vessels, 
they corrupt and contaminate the whole mass, and induce the various 
kinds of cachsemia or cachexia which form the sequels of malarious dis- 
eases. This view accounts for the fact, often considered unintelligible, 
that such remarkable effects result only from enlargements of the spleen, 
and not from its entire obliteration, which has been repeatedly noticed 
to occur without any peculiar effect on the blood. Other instances of a 
similar character will be mentioned under the head of congestion. 

The mode in which amenorrhcea tends to impair the quality and quan- 
tity of the blood particles, may also derive some light from the foregoing 
remarks. A young female, during or before menstruation, is exposed to 
continued cold, or sudden mental excitement; the discharge is checked; 
and if no serious illness immediately ensues, she begins to fade, and in 
a few months becomes chlorotic. The uterine system remains congested 
after the repression of the discharge; and the blood in the system suffers 
not only from the interruption of a process of excretion, (M. Gay Lussac 
and Andral have proved it to be such,) (§ 170,) but also from a reservoir 
of impure blood, which tends gradually to derange and contaminate the 
whole mass. 

192. Remedial Agents. — Excess of the red particles may be speedily 
removed by blood-letting, which reduces these much more than the other 
constituents of the blood. Low or vegetable diet, and the antiphlogistic 
regimen generally, including the avoidance of all stimulating or exciting 
agencies, produce a similar effect more tardily. It is not certain whether 
any medicines directly act in a similar way; but cholagogue purgatives, 
and probably the continued use of mercury, colchicum, and other medi- 
cines w r hich largely increase the excretions (§ 173), ultimately reduce 
this element. Mineral saline waters, and saline medicines very co- 
piously taken in a state of much dilution, sometimes reduce extreme ru- 
bicundity of the surface in so remarkable a degree as to suggest the 
notion that, by their absorption into the mass of blood, they may directly 
destroy some of the red particles; they are, therefore, useful cooling agents 
where these are in excess. The remarkable pallidity which accompanies 
the occurrence of extensive suppuration, would also point to the formation 
of pus as a means of diminishing the red particles, which means may 
be used artificially in the form of setons and suppurating counter-irri- 
tants. 

193. To promote the increase of the red particles, where defective, we 
might expect nourishing food, especially brown meats, exposure to in- 
vigorating air and light, and tonics generally, to be the proper means. 
But without experience, we could not have anticipated that medicines con- 
taining iron should possess such remarkable efficacy in relation to this 
element of disease. In many cases of chlorosis, under the use of any 
suitable preparation of iron, the complexion will change from waxy to 



106 



ULTIMATE ELEMENTS OF DISEASE. 



ruddy, in three or four weeks' time. In the choice of the preparation 
of iron to accomplish this purpose, we must be guided by the state of the 
stomach and other considerations, but where they are borne, the most 
soluble preparations are the most effectual; and this is of more import- 
ance than the particular combinations in which they are administered: 
thus the iodide, sesqui-chloride, sulphate, citrate, acetate, and phosphate, 
are all eligible. This subject will again come under our consideration 
in connection with anaemia. 

It has been supposed by Dr. Stevens that saline medicines have great 
power in restoring to their natural condition the red particles which are 
changed in typhoid and malignant fevers (§ 186) ; but if these remedies 
have any power in such maladies, it is very doubtful how much is to be 
ascribed to this mode of action. A less questionable mode of restoring 
the proper condition of the blood particles, is by promoting the elimina- 
tion of those diseased, by increasing the excretions (§ 192); whilst the 
multiplication of others is aided by the means noticed above (§ 193). 
Thus in malarious and anemic caehsemia, the best effects result from 
the combined use of purgatives and diuretics with chalybeate tonics. 
The disposition of the red particles to coalesce, which is augmented in 
inflammation, may be diminished by the addition of saline matter; and 
Mr. Gulliver has surmised that this maybe a part of the useful operation 
of saline medicines in inflammation. 



SECTION VIII. 

FIBRIN AND WHITE CORPUSCLES. 

194. The trifling difference in chemical composition between fibrin 
and albumen (a minute predominance of nitrogen in the first, Dumas), 
would scarcely distinguish them ; but the organizable property of fibrin 
is that which makes the distinction obvious, and most important in phy- 
siology and pathology. Being the constituent which causes the coagu- 
lation of the blood, with all the varieties which that process exhibits; 
being the part which constitutes the buffy coat and coagulable lymph; 
and being probably the material by which textures are chiefly nourished 
and repaired, its changes must constitute an important element of disease. 
Although probably not so immediately concerned as the red particles in 
maintaining the vital processes of respiration, circulation, and innerva- 
tion, it is yet a representative of the active state of these processes, and 
of the nutritive and reparative function ; and it therefore exists in larger 
proportion and higher perfection in arterial than in venous blood. Al- 
though, as above stated, it is distinguished from albumen less by chemi- 
cal differences than by organizability and susceptibility of life, yet there 
are certain conditions, both chemical and physical, favorable to the forma- 
tion of fibrin, through a knowledge of which we are able to influence 
artificially its production. Fibrin, as presented to us in the washed clot, 
coagulable lymph, or the buffy coat of inflamed blood, consists of a con- 
geries of extremely fine fibres, with transparent granular bodies, separate 



ELEMENTARY CHANGES IN THE BLOOD FIBRIN. 



107 



and in round encysted clusters scattered through them. In fluid blood, 
we see the same encysted clusters or pale corpuscles, but none of the 
fibres. The formation of these fibres seems, then, to be the great charac- 
teristic of fibrin, and its power to assume this form of solid, distinguishes 
it from albumen, which solidifies in a granular mass. So long as fibrin 
remains dissolved, as in the blood liquid, it has nothing to distinguish it 
from the albumen with which it is combined, but it still has the inherent 
capacity to solidify in a peculiar manner. This capacity, from the time 
of J. Hunter to the present, has been generally considered to be an at- 
tribute of inherent life ; and undoubtedly it is connected with vital 
activity in the sanguiferous functions: but various facts, particularly 
some pointed out by Dr. Buchanan of Glasgow, and Mr. Gulliver, show 
that the fibrillation of fibrin, like the crystalization of a salt, is much 
promoted by, and sometimes dependent on, the presence either of fibrin 
already solid, of the pale corpuscles, or of some kindred solid matter. 
Exposure to the air, and dilution with water, also favor the consolidation 
of fibrin. The former is probably also instrumental in its production ; 
for the circumstances which promote the formation of fibrin in the blood, 
generally include a certain degree of increased oxygenation. In fact, 
according to Mulder, fibrin is chemically an oxyprotein, or, more defi- 
nitely, the deutoxyde of protein. 

But although fibrin can be thus designated according to its mere 
chemical and physical nature, we must not lose sight of the peculiar 
relation in which it stands to vital properties, which attach themselves to 
it more than to any other constituent of the blood. Its fibres, cells and 
granules may be regarded as the rudiments of new living textures, and 
in observing its mechanical construction and its chemical constitution of 
deutoxyde of protein, we only note the conditions of a most highly ani- 
malized material, which render it fit for the peculiar properties of life. 

The average proportion of fibrin in the blood of a healthy adult is 
about three in a thousand parts. Within the limits of health, it may vary 
from one and a half to four and a half, being more abundant during 
advancing growth in well fed persons with active circulation; and less 
so in early infancy, and in persons of weakly constitution and advanced 

age- ; ' ' ^ t . , ' - ^ r ' 7 * ' ' 

195. An excess of fibrin, and of the colorless globules, (hyperplasma, 
or hyperinosis,) exists in all true inflammatory diseases, especially those 
of a sthenic character, and those in young subjects, and in acute rheu- 
matism. In some cases, MM. Andral and Gavarret found the proportion 
as high as twelve per thousand. So, likewise, whenever an inflammation 
supervenes in the course of another disease, there is always an augmen- 
tation in the quantity of fibrin. The proportion of fibrin is also increased 
during the latter months of pregnancy.* MM. Andral and Gavarret 
found an increase of fibrin also in tuberculous diseases, in which we have 
noticed there is a deficiency of red particles (§ 185). Mr. Gulliver has 
observed the increase of white globules in blood drawn in inflammation, 
and I have noticed this as occurring within the vessels. (See Inflam- 

* In domestic animals, the fibrin is diminished before, and increased after, parturition. 
(Ann. de Chim., 1842.) 



108 



ULTIMATE ELEMENTS OF DISEASE. 



niation.) There are other diseases in which blood drawn exhibits a 
fibrinous or bufFy coat, as in chlorosis, without there being any absolute 
increase of the fibrin: this will be noticed presently. It is observed in 
various states of atrophy and cachexia, whether from deficiency of blood 
or defective powers of digestion and assimilation, or excessive expendi- 
ture of the nutrient fluid. 

196. Deficiency of fibrin (hypoplasma, or hypinosis) is of frequent 
occurrence in many diseases, and temporary conditions bordering on 
disease. Its sign is fluidity, or imperfect coagulation of the blood when 
drawn. As venous blood contains less fibrin and of a less perfect 
quality than arterial, so the quantity is absolutely diminished when the 
blood is more venous than usual, as in cases of asphyxia or impeded 
breathing; and in those of cyanosis, in which the venous blood becomes 
mixed with the arterial through an unnatural opening. Excessive bodily 
fatigue more or less expends the fibrin: hence the blood often remains 
fluid in animals hunted to death (§ 65). It was stated by John Hunter 
that the same thing is observed in animals killed by lightning; but this 
is not generally the case. In many instances, the blood is found fluid in 
cases of death from poisoning and other sudden causes. In some of 
these, the absence of fibrin may be attributed to the impeded respiration, 
which is the immediate cause of death, as in some cases of death from 
hydrocyanic acid, opium, strychnia, apoplexy, dividing the pneumo- 
gastrics, (Dupuy,) &c. There is, however, some uncertainty about these 
facts. (See Mr. Blake's experiments mentioned further on.) But in 
others, as in poisoning with arsenic, sulphuretted hydrogen, and some 
other pernicious agents, the fluid state of the blood must be ascribed to 
a more direct operation on the blood itself. So likewise in adynamic 
fevers, which arise from a peculiar poison, the fluidity or imperfect co- 
agulation of the blood is one of the most remarkable conditions, and 
seems to be a chief cause of the hemorrhages, petechias, and vibices, 
which sometimes occur in these fevers. In a case of very low typhoid 
fever, Andral found the proportion below one in one thousand. The arti- 
ficial imitations of these fevers produced in dogs inoculated with various 
morbid or putrid matters, or confined over their exhalations, in the ex- 
periments of Gaspard, Majendie, Gendrin, Leuret, and Hamon, exhibited 
a similar absence of fibrin in the blood (§ 194). This absence of fibrin 
was observed by Scherer, in one case of putrid fever, to be accompanied 
by the presence of carbonate of ammonia, doubtless from incipient pu- 
trefaction. 

The addition of some neutral and alkaline salts to the blood out of the 
body will diminish its coagulating property; and it has been stated that 
subsisting on salted food will produce a dissolved or hypoplastic state of 
the blood during life; but this statement does not appear to be founded 
on any well ascertained facts, and is perhaps connected with the notions 
that salt food is the cause of sea scurvy (§ 63), and that the blood does 
not coagulate in this disease, both of which are erroneous. (See Lib. of 
Tract. Med., Art. Scurvy, by Dr. G. Budd.) 

197. Besides the sign already mentioned, permanent fluidity, or little 
coagulation of the blood when drawn, a defect of fibrin causes a tend- 



ELEMENTARY CHANGES IN THE BLOOD — FIBRIN. 



109 



ency to hemorrhages, generally of the asthenic kind, and to an unma- 
nageable oozing of blood from any accidental wound or breach of texture. 
In the same cases, too, wounds do not readily heal, nor fractures unite. 
In fact, the plastic or reparative process is defective for want of its ma- 
terial (§ 194) ; and for a similar reason, the nutrition of textures which 
consist chiefly of fibrin, such as muscle, is ill maintained. 

198. Majendie found that animals, from whose blood fibrin had been 
abstracted, were affected with congestions and effusions in the lungs, 
brain, and other organs, which he ascribes to a cause supposed by M. 
Poisseuille to be a general physical fact: that very thin fluids pass with 
greater difficulty through capillary tubes than those of somewhat greater 
spissitude. But his experiments were too rude and his deductions too 
hasty to merit confidence; and the obstructions and congestions alluded 
to might be equally due to the cohesion of colorless or blood particles, or 
even to little clots of fibrin left by the coarse process employed. There 
can, however, be no doubt that a certain spissitude in the blood is favor- 
able to its transit through the hydraulic apparatus of the circulation ; and 
that when this is deficient, various irregularities in the distribution of 
the blood may occur. Some of these will be mentioned under the head 
of anaemia: but I may mention here that thin blood is easily thrown 
into sonorous vibration, and various unnatural sounds or murmurs in the 
heart, arteries, and veins, may be thus produced. As these are some- 
times met with in cases in which the complexion does not indicate a de- 
ficiency of red particles, and they are sometimes absent in the most pal- 
lid subjects, I am inclined to connect them as much with defect of the 
fibrin and albumen as with that of the red particles of the blood.* 

199. Alterations in the quality of the fibrin introduce to our notice the 
important morbid appearances presented by the buffy coat and contrac- 
tion of the clot of blood. 

As the consolidation of the fibrin is the cause of the coagulation of 
the blood, so differences in the coagulum represent variations in the pro- 
portions and properties of the fibrin. 

200. A large firm coagulum indicates an abundance of fibrin, as well 
as of red particles, and is commonly presented by healthy blood. A 
loose coagulum implies a deficiency of fibrin. A small firm clot be- 
tokens a proportion of fibrin exceeding that of the red particles; but the 
smallness of the clot points to another property of the fibrin, which is in 
excess, that of contraction during and after its consolidation. Again: 
in this case as in others, the upper part of the clot is commonly more 
contracted than the lower portion; it is also firmer, and contains more 
fibrin, whilst the lower abounds more in red particles. Here there is 
evidently a tendency to a separation of the red particles from the fibrin. 
In other cases, again, the separation is to some extent complete, the red 
particles subsiding, whilst the fibrin rises to the surface, and on coagulat- 
ing, forms at the top of the clot a layer of a light yellow or buff color, 
commonly known by the name of the buffy coat. 

* This inference has been confirmed by the subsequent observations of MM. Becquerel 
and Rodier, who found that in the pallid cachexia from the poison of lead, in which the 
albumen is not diminished, the vascular murmurs are not present. 



110 



ULTIMATE ELEMENTS OF DISEASE. 



201. It may be inferred, then, that besides coagulation (§ 194), fibrin 
possesses a property of contraction, and another of separation from the 
red particles; and these properties are presented in different degrees in 
different states of the system. Let us consider these properties, first 
separately, afterwards in combination. 

202. Coagulation is generally retarded in inflammatory diseases, and 
in other cases in which the fibrin is abundant (§ 195); its amount is in- 
dicated by the firmness and size of the clot. Other circumstances, how- 
ever, may make the coagulation slow, as warmth and seclusion from the 
air; whereas cooling quickly, and exposure to the air, as when the blood 
trickles from the vein, or is drawn into a shallow vessel, hasten the co- 
agulation. The addition of some saline matters, such as common salt, 
carbonate or sulphate of soda, also retards the coagulation of the blood. 

203. The contraction of the clot evidently depends on the attraction 
of the particles of fibrin for one another after the coagulation has begun. 
By the contraction, the red particles entangled in the fibrin are also drawn 
together whilst a portion of the serum is squeezed out. The more slow 
the coagulation is, generally the greater will be the contraction. Hence 
the upper surface of the clot is often formed more quickly (§ 202), and 
is therefore larger than that below, whilst the middle portions of this large 
upper film being drawn downwards by the contraction of that below, 
cause the concave or cupped appearance in the clot, so commonly seen in 
buffed blood (§ 200). By drawing blood slowly, or in a shallow vessel, 
the coagulum is speedily formed in all parts, and adhering to the sides it 
is not cupped (§ 202). The contraction and cupping of the clot being 
due to the fibrin, might be expected to be in proportion to its quantity; 
and this is the case in inflammatory diseases. But there is also great 
contraction and often cupping in chlorosis and some analogous states, in 
which the fibrin is not absolutely increased ; the red particles being much 
diminished, the contractile property of the fibrin is not impeded. For a 
similar reason the contraction is greatest where the quantity of fibrin is 
greatest, and most completely separated from the red particles. On the 
other hand, there is little or no contraction where the red particles are in 
proportionate abundance, as in sanguineous plethora (§ 184), or where 
the aggregation of the fibrin is impaired by the addition of saline matter 
(§ 196). In a boy under my care with purpura, Dr. Garrod found the 
fibrin in the blood quite as abundant as usual, amounting to 3 in 1000 
parts, but it' was remarkably defective in the usual contractile property; 
and the salts of the blood were in excess. 

204. The separation of the fibrin from the red particles (§ 200), as 
exhibited in the buffy coat, has attracted much attention, and has been 
ascribed to various causes. As the fibrin always rises to the surface, and 
the red particles sink, it is obvious that a chief cause of the separation 
is the greater weight of the latter, which subside entirely from the upper 
layer of fibrin before it has time to coagulate. Now, this separation may 
be favored by four circumstances — 1, the tardy coagulation of the fibrin 
giving more time for the separation; 2, increased specific gravity of the 
red particles; 3, diminished specific gravity of the fibrin; 4, diminished 
spissitude of the liquor sanguinis. Now two of these conditions may be 



ELEMENTARY CHANGES IN THE BLOOD — FIBRIN. 



Ill 



fulfilled by adding a little salt to healthy blood as it flows from the vein ; 
and this addition really does produce a separation of the fibrin; but the 
fibrin thus rising to the surface has neither the contraction (§ 203) nor 
the firmness of the inflammatory buff, but is gelatinous, like size, and 
rather resembles the sizy blood sometimes exhibited in scurvy and dia- 
betes. Further: although blood in inflammation is generally slow to 
coagulate, it is not so always; and in extreme cases, as in acute rheu- 
matism, the buff appears even where the coagulation is speedy, and, 
according to Schroeder Van der Kolk, is seen in patches and thin films 
where gravitation would not have promoted the separation.* There must, 
then, be some other cause for the formation of the buffy coat besides 
those above mentioned. The great firmness and contraction of the sur- 
face of inflamed blood may be ascribed to the increased proportion of 
fibrin, which is constantly present. 

[Whenever there is excess of fibrin, whether relative or absolute, and 
the coagulation of the fibrin does not occur too rapidly, it will accumulate 
alone on the surface of the clot, and form a buffy coat. Thus the blood 
of ansemia is buffed, whilst that of plethora is not ; the buff in the blood 
of pregnant women is owing to the excess of fibrin relatively to the 
globules. This explains, too, the buff in the blood drawn from horses, 
where there is predominance of fibrin over the red corpuscles. — C] 

205. Dr. Alison considers the separation of the fibrin in inflammation 
to be due to a vital repulsion between the fibrin and the coloring matter. 
Dr. Hermann Nasse and Mr. Wharton Jones think that the tendency to 
separate may be entirely explained by the increased aggregation (before 
noticed, § 190), which they observed in the red particles of inflamma- 
tory blood (Brit and For. *Med. Rev., Oct. 1842, p. 592). This cohe- 
sion of the red corpuscles in separate piles or rouleaux, would facilitate 
the separation, not only by contractile aggregation, but also by sinking 
through the liquid fibrin more quickly than separate particles would; just 
as bits of chalk fall to the bottom of water instead of remaining long 
suspended, as they would do in fine powder. Accordingly, Mr. Gulliver 
has observed that the red particles sink rapidly in proportion to this ag- 
gregation. But another circumstance favoring the separation of the buffy 
coat, is its own increased lightness, due apparently to an increased pro- 
portion of fat globules contained chiefly in the pale corpuscles diffused 
through it. 

The subjoined sections of the different appearances of coagulated 
blood may assist the student to understand their nature and causes. 

206. This presents uniform coagulation with 
little contraction. If the clot be moderately firm, 
the blood is rich in fibrin and in red particles, as 
in that from persons in robust health. If the clot 
be very soft and uniform, the fibrin is deficient, 
as in typhoid fevers, exhaustion from fatigue, &c. 
If the clot be very soft, especially at the bottom, and 
the top covered with a soft, sizy film, the coagulation has been slow, as 
in scurvy and in slight inflammations occurring in typhoid fevers. 

• Alison's Outlines of Physiology, p. 89. 




112 



ULTIMATE ELEMENTS OF DISEASE. 



207. This diagram exhibits uniform coagulation 
with great contraction, which takes place where 
the proportion of fibrin much predominates over 
that of the red particles, as in chlorosis. The 
relative as well as the absolute quantity of the 
fibrin is indicated by the firmness of the clot. 
This appearance, with a buflfy surface, is often 

exhibited by blood drawn in inflammation in anaemic subjects or in ad- 
vanced stages, and in phthisis. 

208. Blood highly bufTed and cupped, as in 
acute rheumatism and other severe inflammations. 
The fibrin here presents in a high degree its pro- 
perties of separation, coagulation, and contrac- 
tion ; having abandoned the red particles, which 
are loose at the bottom of the vessel, and having 
risen to the surface, where it appears as a tough, 

contracted, concave, and buflfy clot. 

209. To exhibit the true properties of the blood in coagulation, it should 
be drawn by a full stream into a deep or globe-shaped basin or cup, pre- 
viously warmed, and kept covered over until the coagulation is complete. 
These precautions retard the coagulation, and favor the separation and 
contraction of the fibrin. On the other hand, if the blood merely tric- 
kles from the vein, as when the orifice is small or the patient faint; or 
when the receiving vessel is shallow and cold, the blood congeals at once, 
and prevents the appearance of the buflfy coat (202). This is one reason 
why blood drawn at one blood-letting often exhibits a different appear- 
ance in different vessels.* 

210. We have before noticed that the fibrin of the blood may be 
speedily exhausted by violent muscular exertion, and by serious impedi- 
ment to the respiration (§ 196). These, and the fact that it exists in 
larger proportion in arterial than in venous blood, seem to point out that 
it is expended in the nourishment of the muscular and other textures, 
and is renewed through the agency of respiration. It might be supposed 
that inflammation increases its quantity by accelerating the circulation 
and respiration without adequate expenditure; but although this may be 
a contributing cause, particularly in acute rheumatism, it is not sufficient, 
for the quantity of fibrin is not proportioned to the frequency of the pulse 
or respiration ; it is often much increased before these are materially 
affected, and in idiopathic fevers it is diminished, although the breathing 
and pulse are commonly accelerated. In fact, various circumstances, 
to be detailed hereafter, render it probable that the increase of fibrin 
during inflammation has its origin in the vessels of the inflamed part. 

211. It has been before stated (§ 194), that the coagulation of fibrin 
in the blood is favored by two circumstances, the presence of the pale 
corpuscles, or of their constituent granules, and the formation of the 
deutoxyde of protein by some oxygenating process operating on the 
albumen: the same circumstances appear to be mainly instrumental in 

* For much interesting information on the coagulation of the blood, the reader is referred 
to the edition of Hewson's Works published by the Sydenham Society in 1846, with the 
valuable notes of Mr. Gulliver. 





ELEMENTARY CHANGES IN THE BLOOD FIBRIN. 



113 



its formation. Thus, as Dr. Carpenter has pointed out, the fibrin appears 
in the chyle of the lacteals after their passage through the mesenteric 
glands; it increases in the thoracic duct, and becomes still more abundant 
in the blood in the lungs where there is a free supply of oxygen. It is 
quite uncertain how much in this process is due to vital influence, but 
there is good ground for belief that much of the change is of a chemical 
nature. The molecular base of the chyle (Gulliver) supplies a congeries 
of minute fat globules which have a tendency to attract around them 
thin films of coagulated albumen (Ascherson), probably identical with 
fibrin or deutoxide of protein; and this process takes place in proportion as 
oxygen is supplied from the adjoining red blood-discs; thus the molecular 
base is converted into single and aggregated granules or pale corpuscles 
of the chyle and blood. The oxygenating process extends further, and 
converts a small portion of albumen into an oxyprotein, still liquid, but 
ready to take the form of a finely fibrillated solid (fibrin) under various 
circumstances before adverted to (§ 194): and the perfection of this 
material, and its susceptibility of the process of further organization, 
form additional characters of fibrin, which appears to belong to the class 
of vital rather than mere physical properties. These will be noticed in 
the next paragraph: but we may observe here that they will much depend 
on the quality of the chemical materials, oil and protein, which the chyle 
and blood contain, and the activity of the processes of circulation and 
respiration, which are continually acting on these fluids. 

212. Fibrin, or the bufTy coat of the blood, is the material of which 
new membranes and cicatrices are formed, constituting the coagulable 
lymph, which is the plasma or basis of the constructive or reparative process. 
In its capacity for this process, fibrin exhibits some varieties. The plasma 
with which old textures are nourished, and new ones formed, is euplastic 
in a healthy state, having a capacity of life, and may become organ- 
ized in a high degree, as in the case of false membranes resulting 
from acute inflammation in a healthy subject. But in many instances, 
this capacity is degraded, and the nutritive material is caco-plastic, sus- 
ceptible of only a low degree of organization, as in the indurations 
resulting from low or chronic inflammation, in fibro-cartilage, cirrhosis, 
gray tubercle, &c. ; or it is aplastic, not organizable at all, as in pus, 
curdy matter, yellow tubercle, &c. It is a fact of great importance, 
that the quantity of fibrin in the blood, and the facility with w 7 hich it 
may be effused, are by no means in proportion to its plasticity, or capacity 
to become organized ; thus it is abundant in the blood, and freely effused 
in the inflammations, of scrofulous or tuberculous subjects, although in 
such the products of these inflammations and of nutrition are commonly 
caco-plastic or aplastic. The fibrin of the blood or coagulable lymph 
in these cases, is more opaque and less elastic than in healthy subjects, 
and under the microscope, presents a predominance of granular matter 
and fat globules, and less of the finely defined fibres and regular nuclei, 
as if it were imperfectly elaborated, and resembled coagulated albumen 
rather than the more animalized form of protein. Even the more perfect 
forms of fibrin, if in a position in w T hich their vitality is not sustained by 
becoming organized, tend to degenerate and become disintegrated into 
8 



114 



ULTIMATE ELEMENTS OF DISEASE. 



an opaque aplastic matter (Gulliver), and this eventually may undergo 
a further chemical change into fatty and calcareous matter, like other 
aplastic deposits. It is interesting to observe that in these cases, also, 
the red particles are defective in number (§ 185); and this suggests a 
probable cause of the imperfection of the plasma. 

213. The coagulation of fibrin is promoted by the contact and motion 
of a rough solid: thus by stirring fresh-drawn blood with a stick, the 
fibrin adheres in shreds to the stick. The same property is exhibited 
within the body in the deposition of lymph (vegetations) on rough surfaces 
within the heart and great vessels, and it is probable that the fibrinous 
concretions called polypi, which are found after death in the heart, are 
formed on its irregular surfaces, as its failing motions cause agitation more 
than propulsion of the blood. The cohesive property of fibrin especially 
characterizes it, and causes it to aggregate in patches and films on the 
surface of membranes; and where it is most plastic, it may be drawn 
into threads or bands. 

Remedial Agents. 

214. Hyperinosis or excess of fibrin (§ 195) is less reduced by blood- 
letting and low diet, than is excess of the red particles; yet these are the 
chief means of effecting this object. It would probably be found that 
purgatives, and other remedies which increase much the more solid secre- 
tions, diminish the fibrin. A similar property has been ascribed to mer- 
cury, to alkaline salts, to iodine, and to antimony: there is a want of 
experimental proof in support of this notion; yet it is favored by some 
analogies, and seems w T ell worthy of fuller investigation.* The operation 
of salts and alkalies in this way was probably suggested by their pro- 
perty of dissolving fibrin out of the body.f 

215. According to the views of Dumas and Liebig, subsisting chiefly 
on saccharine, amylaceous, or gelatinous articles of food, must reduce 
the fibrin and albumen of the blood; and such food is found by experience 
to be the best in inflammatory diseases, in which excess of fibrin is a 
chief element. Is the reputed efficacy of the "cure de raisins," in tu- 

* Dr. Karl Popp, in his elaborate researches on the composition of the blood, infers that 
tartar emetic and nitre, and in a less degree calomel, diminish the amount of fibrin. — Dr. Day 
in Ranking's Abstract, June, 1846. 

t Mr. James Blake (a) has made many experiments by injecting various saline and other 
fluids into the veins, and he has famished me with a summary of their effects on the blood, 
as found after death. 

The blood was found coagulated after the injection of the following matters: — Liquor 
potassae (firmly); carbonate of potass (firmly); nitrate of potass (firmly; blood scarlet); 
nitrate of soda; nitrate of ammonia ; nitrate of lime ; nitrate of baryta ; chloride of calcium; 
chloride of barium ; chloride of strontium; sulphate of magnesia ; sulphate of copper; acetate 
of lead; arsenite of potass; nitric acid (strongly); narcotin (firmly) ; tobacco; strychnia 
(moderately) ; conium ; hydrocyanic acid ; euphorbium ; and water in quantity. 

The blood was not coagulated, or imperfectly so, after injection of caustic soda, carbonate 
of soda, sulphate of soda, ammonia, nitrate of silver, sulphate of zinc, sulphate of iron, phos- 
phoric acid, arsenic acid, arsenious acid, oxalic acid, infusion of galls, of digitalis, alloxan. 

Some of these results are different from what might have been expected; instance the de- 
cided coagulation with potass and its salts, especially nitre, and the fluidity with nitrate of 
silver, sulphate of zinc, infusion of nutgalls, which have been commonly supposed to possess 
a coagulating property. 



(a) [The present Professor of Anatomy in the St. Louis University, Missouri.] 



ELEMENTARY CHANGES IN THE BLOOD FIBRIN. 



115 



berculous disease, connected with the absence of protein compounds in 
the food? Bodily exercise reduces the fibrin, and maybe advantageously 
employed with this view in sthenic plethora and in scrofulous hyperinosis ; 
but is not admissible in inflammatory diseases. Neither can we suggest 
any practicable mode of lessening the fibrin by lowering the function of 
respiration, on which its supply seems to depend, unless narcotics, which 
impair many organic functions, have some action of this kind. The known 
utility of opium, aconite, &c, in rheumatism and low forms of inflam- 
mation, in which excess of fibrin is a constant element, makes this mat- 
ter deserving of some research. Simon mentions one case of phthisis 
long treated with cod-liver oil, in which the fibrin in the blood was re- 
duced in a remarkable degree.* 

216. Hypoplasma, hyponosis, or deficiency of fibrin (§ 196), is to be 
remedied by assisting those functions on which its supply depends, par- 
ticularly those of digestion, circulation, respiration and assimilation, and 
by avoiding its expenditure by too much exercise, and other exhausting 
processes. If the digestive organs will bear them, meat, eggs, bread, and 
other articles of diet abounding in the protein compounds, should be taken. 
The digestive and assimilative functions may be assisted by stimulants, 
bitters, quinine and the mineral acids, which, from their pow 7 er in stop- 
ping passive hemorrhage, in augmenting the muscular substance and 
strength, and in causing the healing of phagedenic and flabby ulcers, 
seem to promote the formation of fibrin more directly, than by their mere 
operation on the digestive organs. To improve the function of respira- 
tion, besides attempts to remove or diminish any disease from which it 
may suffer, the free access of pure cool air to the lungs should be se- 
cured. The injurious effect of exertion is exemplified in the relapses 
which it often induces in continued fever, in which, defect of fibrin in 
the blood is a chief element. Fatigue of every kind, and wakefulness, 
should be carefully avoided, and sleep obtained by narcotics, if it do not 
come naturally. In case of deficiency of fibrin from the presence of a 
febriferous or putrescent poison in the system, it is not to be expected 
that fibrinous food, rest, or any other means, can remove the deficiency, 
so long as the poison remains in active operation. This poison, by its 
septic or analogous influence, interferes with the vital process by which 
the fibrin is formed. But no sooner does the influence of the poison 
subside, as evidenced by improvement in the symptoms, than the quan- 
tity of fibrin increases ; and this sooner than could be explained by any 
increase of nourishment taken. (Andral and Gavarret.) 

217. Very little is known of the power of remedies to correct changes 
in the quality of the fibrin of the blood. The increased properties of 
separation (§ 204) and contraction (§ 203) manifested by blood in in- 
flammation, are reduced by blood-letting and other antiphlogistic reme- 
dies, even more constantly than the excessive proportion of fibrin is by 
the same means; but they seem to be soon reproduced if the inflamma- 
tion continues. Thus, although the last cup drawn in blood-letting may 
exhibit none of the buflfed and cupped appearance presented by the first 
cups, yet blood drawn a few hours after, often show r s as much as any 



* [Animal Chemistry, by Day, p. 230, Am. Ed.] 



116 



ULTIMATE ELEMENTS OF DISEASE. 



taken before. Knowing that this speedy recurrence of morbid proper- 
ties in the blood depends on the influence of the local inflammation, we 
see the necessity of fully using local means, together with those calcu- 
lated to operate on the system. 

The beneficial influence of saline medicines in inflammatory diseases, 
is supposed by Mr. Gulliver to depend on their power to prevent the co- 
hesion of the blood particles, and he suggests the free application of salt 
lotions to an inflamed part. The application of salt to a recent wound, 
is a well-known popular remedy. 

218. Blood-letting and other general antiphlogistic remedies, if they do 
not remove local inflammation, may render its products more injurious by 
lowering their plasticity (§ 211), and approximating them to tuberculous 
and other aplastic deposits. Thus, chronic inflammation continuing after 
the full application of the antiphlogistic treatment, almost surely tends 
to produce degenerated changes of structure, over which remedial art 
has little power. In connection with this subject, therefore, we see how 
desirable it is that inflammations should be removed before they become 
chronic; and when there is a risk of their becoming so, it should be an 
indication to improve the condition of the blood by a tonic and nutri- 
tive plan, at the same time that local antiphlogistic measures may be 
necessary for the lingering inflammation. 

219. A similar tonic treatment is still more indicated in scrofulous, 
chlorotic and other cachectic states, in which the fibrin, although less 
abundant than in inflammation, is yet copious in proportion to the scanty 
red particles (§ 212). Hence the tendency to the deposit of imperfect 
fibrin and granular matter (§ 211), even independently of inflammation; 
and besides means calculated to improve the nutrient functions, and to 
raise the character of their product, it may be necessary to use remedies 
likely to keep the fibrin dissolved, and to prevent its deposit in its aplas- 
tic forms. Alkalies and iodide of potassium have been supposed to have 
some claims to these properties ; but more efficacy seems to attach to 
regiminal and dietetic means, which, excluding all food containing solid 
fat, and protein matters of the lower class (such as casein), secure the 
freshest and most nutrient food, and promote the digestion, respiration, 
capillary circulation and excretion, by healthy air, exercise, frictions and 
suitable medicines. 



SECTION IX. 

ALBUMEN AND OTHER ANIMAL PRINCIPLES DISSOLVED IN THE SERUM. 

220. These form a considerable constituent of the blood, amounting 
on an average to between seventy-six and eighty per thousand in health. 
It is generally supposed that the albumen of the serum is chiefly useful 
as affording the material from which the plasma (fibrin) is elaborated; 
but it is by no means certain that some textures, such as those less highly 
organized, composed of albumen and gelatine, may not be formed at 
once from the constituents of the serum. The albumen is further useful 



ELEMENTARY CHANGES IN THE BLOOD — ALBUMEN. 



117 



in giving to the serum a consistency favorable for its circulation, for 
suspending and preserving the red corpuscles, and in blandly sheath- 
ing the acrimony of the saline constituents. The quantity of albumen 
is estimated by Andral and Gavarret at from 7 to 8 per cent. It may 
be generally inferred from the specific gravity of the serum, which in 
healthy subjects averages at about 1030. 

221. Excess of Albumen exists in most cases of inflammations and 
fevers, especially during their more active stages. Its increase is not, 
however, in proportion to that of the fibrin. Its relative proportion is 
much increased in epidemic cholera ; but this is rather due to the removal 
of the w r ater of the blood. Albumen is the principle least affected in 
its proportions by disease. Very poor living, long continued extensive 
hemorrhages, and other drains on the system, will pretty surely reduce 
it in common with the other animal principles of the blood; but good 
living has less power in raising it above the natural standard. In the 
pallid cachsemia of persons long suffering under paraplegia, it has been 
ascertained by MM. Becquerel and Rodier, that the albumen is not dimin- 
ished, and is therefore, in excess, as compared with the other solid con- 
stituents of the blood. 

222. Deficiency of Jllbumen in the blood is most remarkably met with 
in cases of albuminuria, or disease of the kidney with coagulable urine; 
and this deficiency precedes the diminution of the red particles, which 
takes place in the advanced stages of this disease. Dr. Bright found, in 
a patient with albuminuria, the specific gravity of the serum as low as 
1013. (Bright' s Reports, vol. i. p. 85.) Dr. Babington found the 
specific gravity of the serum in a case of diabetes as low as 1024; in 
another 1027, although that of the blood was higher than usual, 1061. 
In this case the serum was milky. (Cycl. of Anat., Sfc, Art. "Blood.'') 
In theirlatterresearches, MM. Andral, Gavarret, and Delafond, discovered 
a remarkable diminution of the albumen in dropsical sheep affected with 
the rot (a watery state of the blood, with distomata in the liver). Sheep 
in a cachectic state, with deficiency of red particles, but without entozoa, 
were not dropsical, and in these, the albumen was found undiminished. 
It is therefore most probable that the cases of cachexia, or anaemia, 
attended by dropsy, owe this concomitant to a defect of albumen in the 
blood. It is this principle chiefly that gives the blood liquor its spissi- 
tude, which renders it more fit to pass along the vessels, and prevents it 
from transuding through their walls. This deficiency of albumen, there- 
fore, seems to be a chief constituent of the dropsical diathesis. 

We are not acquainted with any means of increasing albumen in the 
blood where it is deficient, further than those which restrain wasting dis- 
charges, and improve general nutrition. A case is mentioned by Simon 
(Animal Chemistry, by Day, [p. 230, Am. Ed.,]) illustrative of the extra- 
ordinary nutritive propertiesof cod-liver oil in phthisis; the solid consti- 
tuents amounted to 25 per cent., the albumen being above 13 ; whilst 
the fibrin, which is usually high in phthisis, was reduced below the nor- 
mal proportion. 



118 



ULTIMATE ELEMENTS OF DISEASE. 



SECTION X. 

OIL. 

223. The oil or fatty matter in the blood sometimes is so much in- 
creased as to give a milky appearance to the serum ; and this increase 
may arise under different circumstances, and from various causes. The 
most common is that originally suggested by Haller, and lately proved 
by Dr. Buchanan, that it depends on the presence of unassimilated chyle 
(•§ 211). The latter physician has ascertained that the serum is gene- 
rally milky in blood drawn four or five hours after a full meal. In other 
instances, this appearance has been observed during illness after long 
fasting, and doubtless proceeds from the absorption of fat from the tex- 
tures, as supposed by Hewson. In some cases, a turbidity in the serum 
has been found to depend on an increased number of minute granules of 
albumen or fibrin, soluble in acetic acid, and not affected by ether. (Vo- 
gel's Path. Anat., by Dr. Day, [p. 48, Am. Ed.] Notes to Hewson's 
Works by Gulliver, p. 85.) Dr. Babington met with an extreme degree 
of milky serum in a case of advanced diabetes. This physician states 
that he has repeatedly found milky serum to have a low specific gravity, 
indicating a deficiency of albumen; and he suggests that the fat might 
originate in a change in the albumen. A similar idea has frequently 
occurred to me, when considering the remarkable instances of fatty 
transformation exhibited in degenerating textures and deposits, and even 
in slowly decaying animal matter, as in the instance of the production 
of adipocire. I shall revert to this subject under the head of Transforma- 
tions and Degenerations. The fat of the blood seems to vary in its na- 
ture ; cholesterine and margarine are often found in old and cachectic 
persons, and often abound in the degenerated tissues and cacoplastic 
deposits of such subjects. 

224. The increase of fat in the textures is probably preceded and 
accompanied by its presence in excess in the blood ; and the circum- 
stances which promote obesity must operate through the composition of 
this fluid. Of these may be mentioned fat, sweet and farinaceous food 
in excess, yet without causing disorder of the digestive organs ; full liv- 
ing with sedentary habits, and especially combined with the free use of 
malt liquors ; imperfect assimilation, often connected with imperfect ex- 
ercise of the respiratory organs, from disease or disuse ; insufficient ex- 
cretion of bile. Exercise tends especially to reduce the fat of the body, 
probably by causing its combustion in respiration, whilst the nutrition of 
muscular textures is increased by the same influence. Thus, unhealthy 
fat commonly increases at the expense of strength, and is reduced in pro- 
portion as muscular power is restored. In addition to the use of as much 
exercise as the strength will bear, and the invigorating influence of pure 
air, and the avoidance of all fat and other articles of food abounding in 
hydro-carbon, some advantage may be derived from the employment of 



ELEMENTARY CHANGES IN THE BLOOD — SALINE MATTER. 119 



food and medicines, in which oxygen and azote predominate, such as 
nitric acid, benzoate of ammonia, and some vegetable acids. 

Defect of fat in the blood has not, to my knowledge, been observed, 
but it may be presumed to occur in cases of inanition and emaciation of 
long standing, particularly in those of advanced stages of malignant dis- 
ease and tabes mesenterica. This element of disease, and the still more 
important one of alteration in condition of the fat globules which form the 
basis of nutrition, will be better considered under the head of diseased 
nutrition, when the remarkable powers of the cod-liver oil as a remedy, 
will demand our attention. 



SECTION XL 

SALINE MATTER. 

225. The saline matter dissolved in the blood tends to preserve the 
form of the red particles, and the fluidity of the fibrin. Vogel states that 
it is in excess in scurvy, and causes the hemorrhagic disposition in that 
disease, but this does not accord with what has been observed in this 
country (§ 196). He also thinks that the same cause renders the red 
corpuscles granular or puckered at their margin by withdrawing some of 
their fluid contents. Such an appearance of the red particles, as well as 
an excess of saline matter, exists in the blood of a boy with purpura, 
now under my care. 

There can be little doubt that the thirst induced by salt food is con- 
nected with an excess of saline matter in the blood, which causes a 
shrinking in size of the red corpuscles, and wherever they circulate, they 
attract by endosmose fluid from the textures and surfaces, exciting that 
demand for liquid which the feeling of thirst is intended to supply. 

226. Diminution of saline matter in the blood has been said by Dr. 
Stevens, to take place in yellow fever and other pestilential diseases, and 
to cause so dark and grumous a state of the blood, that exposure to air 
will not, as usual, render it florid. This fact has been more distinctly 
ascertained by Dr. O'Shaughnessy, with regard to malignant cholera, in 
which the defect of saline matter and w r ater seems to be the immediate 
cause of the obstructed circulation, lividity and collapse, so remarkable 
in that terrible disease. Accordingly, Dr. Mackintosh found the blood 
extensively coagulated in the heart and large vessels. There can be 
no doubt, therefore, that in the extreme cases just mentioned, the blood 
coagulates in the vessels for want of saline matter, and the red particles 
become dissolved and altered. 

227. Hence the temporary efficacy of injection of saline solutions into 
the veins of cholera patients; it seems at once to renew circulation, re- 
spiration, warmth, and other functions — life, in fact, to the patient — as if 
the saline solution were all the thing needed. But this defect of serum 
in the blood is only an effect of the excessive evacuations from the sto- 



120 



ULTIMATE ELEMENTS OF DISEASE. 



niach and bowels ; and if these go on, the good effect of saline injec- 
tions is soon exhausted. 

The researches of Andral scarcely support the notion that similar 
changes take place in typhus fever, as supposed by Dr. Stevens. If 
saline medicines are useful in common continued fevers, it is a question 
whether it is in this way, by supplying what is defective ; it may rather 
be by augmenting deficient secretions (§ 171), and tending to remove or 
counteract septic influences present in the system (§§ 98, 105). 

It is stated by Henle that a diminution of saline matter takes place 
within inflamed blood-vessels ; but this statement seems to be no more 
than an assumption to aid his favorite explanation of the obstruction in 
inflammation. 



SECTION XII. 

WATER. 

228. The average proportion of water in healthy blood may be stated 
at about 80 per cent. It is obvious, from what has been already noticed, 
that this proportion increases as that of the animal contents decreases. 
Thus, after extensive hemorrhages, and in chlorosis and other cachectic 
states attended with anaemia, the blood is more watery than usual. The 
effect of this state of the blood is to cause a tendency to dropsical effusions 
and fluxes, besides the consequences which result from a deficiency of 
the other constituents of the blood. 

229. I have before suggested a question (§ 187), whether the serious 
functional disturbance sometimes following the ingestion of very large 
quantities of liquids, particularly after exertion, when absorption is active, 
may not in some degree arise from the too copious and sudden addition 
of water to the blood. Certainly temporary plethora, with palpitation, 
feeling of oppression or dyspnoea, often results from the too free ingur- 
gitation of liquids, and is not removed until perspiration, or a free 
flow of urine, relieves the distended vessels. These symptoms are most 
distinctly observed where some permanent disease of the organs of cir- 
culation or respiration incapacitates them for the increased task. Hence 
the aggravation of the symptoms of disease of the heart and lungs, by 
too much drink. The colliquative sweats in phthisis seem to arise from 
a similar cause, and may often be relieved by a judicious reduction in 
the quantity of liquid food. 

230. Deficiency of water in the blood is exemplified in epidemic cho- 
lera, in which the specific gravity of the serum has been found as high 
as 1045 (Lecanu), which implies a reduction of nearly half the natural 
proportion of water. Some diminution probably takes place in other 
diseases attended by profuse watery discharges, such as diarrhoea, diabetes, 
and excessive sweating. In these cases, the smailness of the pulse, and 
sometimes the shrunk appearance of the surface from the undistended 
state of the vessels, are signs of the diminished bulk of the circulating 
fluid; and thirst pretty constantly points out the mode which nature 



ELEMENTARY CHANGES IN THE BLOOD — BY RESPIRATION. 121 

prompts to remedy the defect. In the same way, exposure to heat, 
especially if continued, and prolonged violent exercise, expend the water 
of the blood, and cause the feeling of thirst through which it may be 
restored. Long abstinence from liquids has a similar effect. 

It has been already mentioned, that the extraordinary decrease of the 
water of the blood which occurs in malignant cholera, renders the blood 
so thick, that it cannot circulate freely, and this change is the chief cause 
of the cessation of the pulse, lividity, and other signs of obstructed cir- 
culation. No such effect is known to follow from any of the other causes 
of deficient water. The operation of heat and continued exertion is not 
simple, and therefore not referable to this principle only. Abstinence 
from liquids for two or three days induces languor, small, and easily ac- 
celerated pulse, a somewhat pasty state of the mouth, and scantiness and 
turbidity of the urine, but little derangement of other functions. The 
digestive process, which might be expected to suffer, in some cases at 
least, shows no symptoms of disorder. 

231. We thus have means of increasing or reducing the water of the 
blood by increasing or diminishing the liquids drunk; and these expe- 
dients may be usefully employed in the cases above mentioned. But 
these expedients in their extremes also furnish us with therapeutic agents 
of more extensive power. Drinking large quantities of water may, in a 
salutary manner, excite the whole vasculur system and its connected 
secreting organs, and may thus wash out of the blood various effete or 
noxious matters; and this is a chief good which the "water-cure" 
sometimes effects. The free use of liquids is supposed, by Prout, to 
prevent the formation of lithic acid, or, according to Liebig, it facilitates 
its conversion into urea. On the other hand, a total abstinence from liquids 
for two or three days, is an effectual mode of stopping fluxes, and of re- 
lieving catarrhal inflammations and congestions. Either plan exerts an 
alterative operation on the circulation and secretions, w T hich, if more 
studied, may perhaps be turned to good account in the treatment of many 
diseases. 



SECTION XIII. 

CHANGES IN THE BLOOD BY RESPIRATION. 

232. The process by which venous blood is made arterial, and rendered 
fit for its purpose of maintaining the life and functions of the several parts 
of the body, is liable to variations ; and the resulting differences in the 
state of the blood form an important element of disease. 

The conversion of venous into arterial blood comprises the absorption 
of oxygen, the removal of some carbonic acid and water, a slight in- 
crease of fibrin, and possibly other changes. Each of these elements of 
the process is probably concerned in giving to arterial blood its fitness 
for its function; the absorbed oxygen, by its affinity for the hydrogen and 
carbon of the blood and textures, aiding in those processes by which 



122 



ULTIMATE ELEMENTS OF DISEASE. 



these are renovated in function as well as in structure, superfluous fat, 
and other combustible matters consumed, and heat is evolved ; the re- 
newal of fibrin supplying the expenditure of the plasma, particularly in 
the muscles ; and the removal of the carbonic acid being the excretion 
of a noxious matter. 

233. It is doubtful whether this change is ever carried on in excess; 
for by an admirable adaptation, the activity of respiration is proportioned 
to the rapidity of the circulation and the corresponding need of change in 
the blood. Thus exercise, which accelerates the circulation and changes 
of the blood, also augments the breathing movements. In fevers, also, 
the frequency of the pulse and of respiration is increased; but the mus- 
cular strength being much impaired, it is doubtful whether the rapidity of 
the circulation or the real amount of the respiratory changes is generally 
augmented in proportion. It has been said, that in acute rheumatism, 
the circulation and respiration are too active for the wants of the system, 
and that the blood reaches the veins without having wholly lost its arte- 
rial character. If this were true, it might in some measure explain the 
great increase of fibrin in the blood in this disease; but the fact is not 
well established.* 

234. Defect of the change in the blood by respiration is a common 
and important element of disease, and constitutes a chief feature of affec- 
tions of the respiratory apparatus. Being the essence of the special 
disease asphyxia or apucea, its minute consideration belongs to special 
pathology, and we shall here only describe it in its more general cha- 
racters. 

The amount of mischief arising from defective respiration, varies 
greatly according to the sudden or the gradual supervention of the de- 
fect. An acute attack of the organs of respiration may prove distressing, 
and even fatal, by an impediment to the breathing, much smaller than 
that caused by chronic diseases, the gradual infringement of which may 
be scarcely perceived. Thus, too, persons affected with extensive emphy- 
sema of the lungs, are habituated to an imperfect state of respiration, 
which is shown by a constant lividity of the lips and cheek; such an 
appearance would be a sign of approaching death in other persons. The 
cause of this difference is not merely the general fact that sudden changes 
produce more effect than slow changes, but it lies chiefly in the fact that 

* It seems to me, that Professor Liebig has given too mechanical a view of the change 
of the blood in respiration. He appears to consider the increased arterialization of blood, 
during exercise, and on exposure to cold, to be a necessary consequence of the greater amount 
of air inhaled, in one case by accelerated movements of the chest, in the other, by the greater 
density of the cold air. But if the extent of the changes wrought by respiration were in 
exact proportion to the quantity of oxygen received into the lungs, how easy would it be to 
increase them (and thereby animal heat also), by voluntarily augmenting the respiratory 
movements. I cannot but think that the proportion of oxygen absorbed, and of carbonic acid 
expired, depends more on the condition of the blood brought to the lungs, and that the re- 
spiratory movements are regulated by this. Thus the increased oxygenation of the blood is 
a consequence of greater changes previously wrought in the blood itself, and not a mere re- 
sult of a fuller access of air. In confirmation of this view, I may mention an experiment 
which any one can repeat ; if a succession of moderately deep and quick respirations be 
performed during several minutes, at a pretty low temperature, the effect is to cause feelings 
of chilliness and faintness rather than of increased warmth and energy ; it is like extinguish- 
ing a fire by overblowing it. 



ELEMENTARY CHANGES IN THE BLOOD BY RESPIRATION. 



123 



the importance of the respiratory function varies under different cir- 
cumstances. When the several parts of the body, especially the mus- 
cular, are in a state of full activity, more breath is needed to remove 
from the blood the noxious effete matter which always results from func- 
tional exercises. Hence in such a condition (which is that of healthy 
action), the respiratory process cannot be abridged without serious dis- 
order. This disorder is first obvious in the increasing feelings of oppres- 
sion and suffocation w T hich the w T ant of breath causes, and which excite 
forced exertions to breathe. If these exertions still fail to duly aerate 
the blood, it is partly arrested in the lungs, right compartments of the 
heart and veins, and part passes in an imperfectly arterial state to the 
left side of the heart and arteries. 

235. The phenomena of asphyxia are thus compounded of — 1, accu- 
mulation of blood in the venous system ; 2, diminution of blood in the 
arterial system; and 3, deficiency of oxygen and excess of carbonic acid 
in the blood. These several conditions cause injury to the vital func- 
tions, both by the w T antof a due supply of blood, and by the bad quality 
of that blood, which is injurious, — negatively for want of oxygen, the 
proper exciting agent, and positively from its excess of carbonic acid 
and other excrementitious matters which are sedative. The symptoms 
induced are also of two classes — 1, those implying failure of function, 
such as muscular debility, feeble action of the heart, pallor and coldness 
of the surface and extremities, and abolition of the senses and mental 
faculties; and 2, those arising from congestion and the noxious influence 
of the black blood, such as palpitation, flashes in the eyes, noises in the 
ears, delirium, muscular spasms, &c. Each of these sets of symptoms 
may predominate in different cases, and this causes a variety in the phe- 
nomena of asphyxia, which has not been sufficiently noticed by writers 
on this subject. 

236. But w T e have to notice the other mode in which the changes by 
respiration may become defective, that occurring gradually, or when the 
functions are not active. It is w T ell known that hybernating animals 
breathe scarcely at all, and yet they live ; and this is obviously because 
their functions are reduced to an extremely torpid state. So, too, 
animals newly born will bear the privation of air for a much longer 
period than those which are older; and it has been supposed that in adults 
failure of the heart's action by syncope retards the operation of asphyxiat- 
ing causes. (Dr. Carpenter, on Asphyxia, Library of Med., vol. 2.) 

237. Although a man cannot be reduced to the torpidity of hyberna- 
tion, yet it is certain that he may be brought to bear a defect in the re- 
spiratory changes, which w T ould be fatal in a few minutes under common 
circumstances. This is seen when the defect is congenital, as in those 
affected with malformations of the heart causing cyanosis; and it is also 
seen where the defect is very gradually induced, as in the case of em- 
physema of the lungs. 

238. In cases of cyanosis, (the blue disease, in which, from malfor- 
mation of the heart, some venous blood passes into the arteries,*) w r e 

* [Dr. Williams here adopts the old, and now almost exploded pathology of congenital 
cyanosis. It has been satisfactorily shown by Drs. Johnson, of London, West, Moreton 
Stille and Dunglison, of Philadelphia, Craigie, of Edinburgh, Louis and Valleix, of Paris 3 



124 



ULTIMATE ELEMENTS OF DISEASE. 



have the opportunity of observing the more essential effects of defective 
arterialization of the blood. Individuals thus affected, are in a lower 
scale of animation. The slower processes of nutrition and secretion 
seem to go on pretty well, but the muscular power is low ; slight exer- 
tions bring on symptoms of faintness, palpitation, suffocation, or insen- 
sibility: the animal heat is lower than natural, and there is greater suf- 
fering from the influence of cold. In short, all the powers of body and 
mind are slender, and are easily disordered by any circumstances which 
tax their activity. In the few that reach mature age, there is no sexual 
passion, which seems to be a happy provision against the chance of per- 
petuating a race of malformed beings — human reptiles. The subjects 
of cyanosis are said to be very liable to hemorrhages, and when these 
occur spontaneously, or from accidental causes, it is very difficult to 
stop them. This must be ascribed to the deficiency of fibrin, which we 
have already found to occur where the changes of the blood by respira- 
tion are imperfect (§ 196). The same peculiarity occurs in the foetus. 

239. In connection with the scantiness of fibrin in the blood, when 
the respiratory changes are defective, we must notice the weakness of 
the muscles generally, which are probably nourished by the fibrin. This 
weakness is often observed in the subjects of extensive disease of the 
lungs, especially emphysema. In these same subjects, the deposition of 
fat is, on the other hand, often excessive, which agrees very well with 
Liebig's idea that respiration directly consumes the oily parts of the 
blood; the respiration being defective, the fat accumulates (§ 224). 

240. Remedial Measures. — Besides the obvious indication of endeavor- 
ing to restore the respiratory function where it is defective, the view 
which we have taken of the mode in which the defect is hurtful (§ 234), 
suggests means by which its injurious effect may be diminished. Thus 
circumstances which lower the activity of the functions, often give relief. 
Of these, complete rest to body and mind, warmth to the surface and 
extremities, whilst air is supplied cool and fresh to the face and air- 
passages ; and various sedatives, which reduce the circulation and other 
functions to a lower standard, (or, in the language of Laennec, diminish 
the want of breath,) such as digitalis, conium, hyoscyamus, &c, are the 
chief. Other medicines, such as ether, belladonna, stramonium, lobelia, 

and particularly Norman Cheevers, of London, with many others, that this affection is not 
due to the direct admixture of venous with arterial blood — at least, in a large majority of 
cases. Louis was the first, we believe, to show that an opening might exist between the 
right and left sides of the heart, without the production of the cyanotic hue ; and, that this 
condition might be present without any malformation of that organ. His observations, made 
prior to 1826, have been since abundantly confirmed by the authorities above quoted. The 
same distinguished observer then expressed the opinion that, in many cases, the disease in 
question was caused by congestion, due to some impediment in the venous circulation. Dr. 
Moreton Stille, in an able inaugural essay on Cyanosis, attempts to show by the analysis of 
a number of cases, that the pulmonary artery was uniformly either imperforated, contracted, 
or obstructed, or that some physical obstacle to the natural course of the blood of analogous 
action existed, and "that the essential characteristics of cyanosis are constituted by general 
venous congestion," and "that it depends simply upon any cause which, acting at the centre 
of the circulation, will produce a stasis of venous blood in the capillary system." (a) The 
extensive researches of Dr. Norman CheeVers (6) confirm the views held by Dr. Stille.— -C.J 



(a) Am. Journ. Med. Sciences, N. S., vol. viii. p. 25, 1844. 

(b) Lond, Medical Gazette, March, 1847. 



ELEMENTARY CHANGES IN THE BLOOD BY RESPIRATION. 



125 



&c, which sometimes relieve dyspnoea, probably act in another way, by 
relieving spasm or other impediments to the respiration. 

241. In extreme cases, bordering on asphyxia, the enfeebled circula- 
tion may require stimulants (§ 235), and the engorgement of the venous 
system may indicate depletion ; in different instances, each of these con- 
ditions may most need attention, and sometimes both must be treated in 
the same case. It appears from the researches of Chossat, Erichsen, 
and others, that no stimulant is so generally useful as that of heat to the 
whole body ; and in the experience of the officers of the Royal Humane 
Society, the warm bath has been found the most useful remedy in restoring 
animation suspended by submersion. Warm frictions, and stimulating 
applications, are likewise very serviceable in exciting the failing circu- 
lation. 

242. Experience has not yet furnished us with the means of arterial- 
izing the blood by any other process than that of respiration. This pro- 
cess may, in some cases, be aided artificially, either by mechanical 
means, as inflation of the lungs, electricity applied to the muscles of 
respiration, the diaphragm, and abdominal muscles alternately ; and by 
bronchotomy ; — or by chemical means, the supply of oxygen or nitrous 
oxide for respiration. Whether the internal administration or the injec- 
tion into the veins of saline and other matters, containing much oxygen 
in loose combination, such as the chlorates, nitrates, and some peroxides, 
may be made in any degree to supply the defect of respiration, is uncer- 
tain, but it deserves more extensive trials than it has received. If these 
matters could furnish oxygen to the blood, they would yet leave undone 
the other office of respiration, the removal of carbonic acid. Might this 
be accomplished by the administration of free alkalies? In some cases 
of asphyxia by carbonic acid gas, % I have thought that some benefit in 
the progress towards recovery, was derived from the use of liquor potassae, 
with chlorate of potash. Perhaps warm baths containing these ingre- 
dients might be of some use. Friction of the surface of the body with 
solutions of these and similar matters, might also prove serviceable. 

243. The congested state of most organs which occurs when the 
respiratory process is imperfect, renders necessary remedies suited to 
remove this state; and it is from a disregard of this consequence of 
imperfect breathing, that many fall victims to the secondary effects of 
apncea. The lungs, the brain and the liver suffer most. The best re- 
medies in these cases are mercurial and other medicines, which act freely 
on the secretions (§ 173). Probably, these remedies act, in part, by 
making the liver assist the lungs in the office of decarbonizing the blood. 
The speedy relief afforded to dyspnoea by a bilious diarrhoea, has several 
times seemed to me to countenance this notion. 

244. When, from disease, the respiratory changes are reduced to a 
narrower sphere, it becomes an object not to increase the hydrocarbon of 
the blood by the use of food with much fat, or containing spirit, but to 
make lean meat, and other fibrinous articles, with farinacea, and fruit 
abounding in vegetable acids, the chief sustenance. 

245. There is little to be said on the subject of excess of changes in 
the blood by respiration, as it is not certain that such a condition ever 
exists as an element of disease. It has been supposed, that, in most 



126 



ULTIMATE ELEMENTS OF DISEASE. 



sthenic febrile diseases in which the function of respiration is not im- 
paired, this function must be more active in proportion to the accelerated 
circulation. Acute rheumatism gives an example of this kind, and Dr. 
Christison states that the blood drawn from a vein is much more florid 
than usual. If this be a correct observation, this hyper-arterialization 
of the blood may, perhaps, account for the unusual quantity of fibrin 
which it presents in this disease. I must, however, remark that I have 
found the excess of fibrin in cases in which there had been no remark- 
able acceleration of the pulse or respiration. We shall see, hereafter, 
that the increase of fibrin is connected rather with the local inflamma- 
tion than with the fever. 

246. From the experiments of the late Mr. Broughton, it appears that 
when animals are confined in oxygen gas, they, in the course of a few 
hours, die comatose ; the respiration first ceases, whilst the heart conti- 
nues to beat with vigor, and the blood, even in the veins, is quite florid ; 
it also presents the arterial character of very speedy coagulation. It 
appears, then, that excess of oxygen injures first the nervous function 
(.§ 154); but whether it does so by exhausting it by previous excitement, 
or by the coagulability of the blood, or by the excessive production of 
carbonic acid, is not decided by any known experiment. The last- 
named mode is the most consistent with the related phenomena ; it can 
scarcely be doubted that an increase of oxygen in the blood must aug- 
ment the production of carbonic acid; and that this latter agent may 
asphyxiate independently of the exclusion of oxygen, appears from the 
experiment of Rolando; he found that the air-tube of one lung of the 
land-tortoise maybe tied without materially injuring the animal; but 
if one lung were supplied with carbonic acid gas, whilst the other re- 
ceived air, the animal died in a few hours. [Carpenter'' s Human Phy- 
siology, p. 590, 3d Amer. Ed.] 

347. Liebig appears to suppose that the poisonous action of hydro- 
cyanic acid and sulphuretted hydrogen, is due to their rendering the 
iron of the red particles of the blood incapable of absorbing oxygen from 
the air, and becoming thus the medium of its transfer to the blood and 
tissues; but to this hypothesis it may be objected, that the blood of an 
animal poisoned with hydrocyanic acid, exhibits the usual changes on 
exposure to the air. Sulphuretted hydrogen does seem permanently to 
injure the composition of the blood, but not of the red particles merely ; 
for it renders the blood fluid, as well as of a dirty red color. It does 
not seem consistent with analogy, to exclude the fibrin and albumen from 
a share in the absorption of oxygen, as well as in furnishing the material 
on which that oxygen afterwards acts.* 

* The opinion thus expressed in the former edition, corresponds with the views of Mul- 
der, Scherer and others, subsequently published ; but these chemists seem to me to go to the 
opposite extreme, in assigning to the protein the chief share in the process of absorbing 
oxygen. Many facts (§§ 183, 188) combine to prove that the red corpuscles are pre-emi- 
nent in their power to absorb and convey oxygen, although it is by no means certain by what 
chemical property they hold it. 



ELEMENTARY CHANGES IN THE BLOOD — BY EXCRETION. 127 



SECTION XIV. 

CHANGES IN THE BLOOD BY EXCRETION. 

248. Having already noticed this subject under the head of diseased 
secretion (§ 158), it will be unnecessary to dwell long on it here. 

The most remarkable instance of change in the blood from disordered 
secretion, is exhibited in defective secretion of urine (§§ 70, 170). The 
extreme effects of this element of disease were shown in animals in 
which the kidneys had been extirpated, in the experiments first performed 
by Prevost and Dumas. On the third day after the operation, there came 
on vomiting, diarrhoea of a copious brown liquid ;* fever, with heat vary- 
ing sometimes as high as 110°, and sometimes as low as 92°; pulse 
very small and frequent ; breathing labored : death ensued from the fifth 
to the ninth day. After death, there w T ere found effusion of serum in the 
brain, copious mucus in the bronchi, and bilious fluid and feces in the 
intestines. The liver appeared inflamed (?) and the urinary bladder 
much contracted. The blood was more watery than natural (222), and 
was found to contain urea: five ounces of blood of a dog yielded twenty 
grains of urea; and two ounces of cat's blood, ten grains. 

249. The symptoms induced in defective secretion of urine by degene- 
rative disease of the kidneys, are very similar to those just mentioned, 
but more diversified, from the defect taking place in different degrees as 
to amount and time. Thus, in acute cases of albuminuria, or acute 
aggravations of old ones, there may be epileptic convulsions, low delirium., 
and other typhoid symptoms passing into coma (§ 129), suffocative catarrh, 
obstinate vomiting, diarrhoea, or inflammatory effusions in the serous 
cavities, any of which may end in death. In slower cases, cachexia 
and dropsy may ensue, the blood and solid structures becoming altered. 
All these effects may be traced to excrementitious matters being retained 
in the blood, especially urea, which has in very many instances been 
detected in considerable quantities; in the greatest amount acting on the 
nervous system as a narcotic poison (§ 129) ; in smaller, acting as an 
irritant, inducing low inflammations in various membranes and viscera; 
and in still lower degree causing sundry functional disorders, fluxes, and 
dropsies, impoverishing the blood, and inducing degeneration of certain 
textures (§ 212). It has been already mentioned that the blood in albumi- 
nuria loses its proper amount of red particles (§ 185), and of albumen 
(§ 222), and the diminution of these assists in accounting for the weak- 
ness, dropsy, and degenerations which commonly ensue in protracted 
cases. The several results now enumerated may be differently presented 
in different cases, and the treatment should be guided according to them. 

* From the recent researches of Bernard and Barreswil, it appears that the matter ex- 
creted from the intestines contains a quantity of ammoniacal salt which results from the 
elimination of urea from their surface. — Dr. Day's Lectures on Animal Chemistry, Med. Gaz. } 
Sept., 1347. 



128 



ULTIMATE ELEMENTS OF DISEASE. 



250. The effects on the blood of a defective secretion of bile have not 
been so accurately determined. The presence of the bile is often obvi- 
ous in the yellow color of the serum and fibrin, which gives the charac- 
teristic green on the addition of nitric acid, and in such cases, analysis 
has discovered, besides the bilin and the biliphsein, an increase of fatty 
matter to double or treble the ordinary proportion. In several cases of 
fatal j aundice connected with structural disease of the liver, I have observed 
extensive ecchymoses on the legs, which probably are due to the destruc- 
tive influence exercised by bile on the red particles (§ 187); and I have 
already stated (§ 171), that in most of the cases of purpura which I have 
seen, there has been imperfect action of the liver, and the most effectual 
treatment was by medicines which this circumstance would suggest. 
The presence of bile in the blood, although sometimes causing tingling, 
pruritus, and cutaneous eruptions, does not appear to produce local irri- 
tation and inflammation, or change of the blood and general dropsy, so 
remarkably as that of urea does. Still it appears from very prolonged 
cases of jaundice, in which the dropsy is not local merely (ascites), but 
general (anasarca and hydrothorax), that the blood at last is impoverished, 
and the whole body becomes cachectic. Andral found that in dropsical 
sheep, with flukes in the liver, the albumen, as well as the red particles 
of blood, was diminished. Symptoms of giddiness, faintness, and 
drowsiness, often occur in connection with imperfect action of the liver, 
such as is commonly designated by the term bilious attack, and are re- 
lieved by medicines which promote a free flow of bile ; butwhether they 
are caused by retention of the excrementitious matter in the blood, or by 
the sympathy (§ 152) of the brain and heart with the stomach and liver, 
is uncertain. 

251. The perspiratory secretion contains lactic acid and lactates of 
soda and ammonia, which probably proceed from the transformation or 
decay of the textures, particularly the muscular, which the recent re- 
searches of Liebig have shown to contain a preponderance of this acid 
{Chemistry of Food, fyc, 1847). Hence these products abound during 
great muscular exertion ; and when perspiration is checked by external 
cold (§ 77), they may be retained in the blood, causing rheumatism, uri- 
nary disorders, or various cutaneous diseases. The very serious effects 
sometimes resulting from sudden cold on the perspiring body may be 
partly owing to the same cause, as well as to the disorder produced in 
the circulation.* Rheumatism is especially liable to occur as an effect 
of cold, where the body is fatigued with much muscular exertion (§ 30); 
and I have frequently observed that the rheumatism chiefly affects the 
limbs which have been most exercised. Where the skin fails to excrete, 
an increased task is thrown on the kidneys, whence may result various 
diseases of these organs ; and if these organs fail in the task, the lactic 
acid accumulates in the blood, and, probably acting as a ferment (§ 56), 

* Dr. R. Willis has recently suggested that checked perspiration may prove hurtful by 
rendering the skin dry, and therefore unfavorable for vital changes supposed to take place in 
the cutaneous capillaries. But if this were the only or chief cause of mischief, it might be 
always removed by the warm bath, or any other means of moistening the surface ; in like 
manner, pernicious effects should always result from a dry state of the skin : neither of these 
consists with facts. 



CHANGES IN THE BLOOD — BY TRANSFORMATION. 



129 



causes the formation of more, and of the kindred products, lithic acid and 
its compounds and products; these, in inflammatory subjects, excite 
rheumatic fever; in cachectic persons, miliary fever, erysipelas, or pem- 
phigus : and in more torpid frames, various local rheumatic or gouty 
affections. All these cases are frequently remarkable for the acid cha- 
racter of the cutaneous and renal excretions,* and in a few instances the 
blood has been found to possess acid qualities, or to be deficient in its 
usual alkaline reaction. (Dr. Day's Vogel, [p. 84, Am. Ed.] ) In low 
forms of rheumatism, especially the neuralgic, the materies morbi is pro- 
bably oxalic acid, as originally suggested by Dr. Prout, for I have in 
numerous instances found an abundance of the octahedral crystals of 
oxalate of lime in the urine, especially when the patients begin to conva- 
lesce. 

252. The remedy for rheumatism and other diseases arising from de- 
fective excretion, therefore, should not be merely antiphlogistic, but also 
of a kind calculated to eliminate the morbid matter from the blood. In 
slight cases of rheumatism, sudorifics may suffice ; but in others, the kid- 
neys and liver should also be excited to assist in the process of elimina- 
tion, and various combinations of colchicum and alkalies with mercury, 
opium, and iodide of potassium, will generally effect this purpose very 
satisfactorily, and both speedily and permanently remove the disease.! 
Where the disease is more decidedly asthenic, and the urine exhibits a 
deposition of oxalate of lime with or instead of lithates, or acid phos- 
phates, great advantage may be often derived from the use of means cal- 
culated to raise the tone and vital energies of the circulating and secret- 
ing organs, such as bark, quinine, arsenic, and iron ; and they are the 
more eligible in cases of neuralgic rheumatism, because the attacks are 
periodic, with intervals of depression highly favorable to the use of these 
remedies. 



SECTION XV. 

CHANGES OF THE BLOOD FROM THE TRANSFORMATION OF CHYLE AND OF 

THE TEXTURES. 

■ » if? 

253. The changes of the blood from the transformation of the chyle and 
of the textures, including the processes of nutrition and reparation, have 
been examined too little to supply the pathologist any certain data. 
Prout, Liebig, and other organic chemists, have advanced interesting 
views on these subjects, but they are too hypothetical to be strictly ap- 
plicable to medicine. It seems quite warrantable, however, to connect 
with these changes some remarkable states of disease, on the pathology 

* In patients with acute rheumatism, I have frequently found the perspiration of the af- 
fected joints more strongly acid than on other parts. 

"j" The advantages of this due regard to the essential elements of disease in the treatment 
of rheumatism may be shown by the fact, that, in upwards of two hundred cases of various 
forms of rheumatism, under my care in University College Hospital, the convalescence was 
established in from three to six days on an average, and the patients were dismissed cured 
in from one to three weeks after. 

9 



130 



ULTIMATE ELEMENTS OF DISEASE. 



of which chemistry has thrown much light, gout and other lithic acid dis- 
eases (§ 176), diabetes, both saccharine and ureal, and obesity. 

254. Gout, and the commonest kind of urinary gravel, are now gene- 
rally considered to depend on the production in the system of an excess 
of lithic acid.* This acid being a highly azotized compound, is abun- 
dantly generated in those who take a large proportion of animal food, 
and in whom the digestive and assimilative processes are impaired; and 
the more the processes are weakened, and the less digestible and assi- 
milable the food supplied to them, the more surely will this acid with 
ammonia, the products of degenerating decomposition, result. Hence 
it is engendered not only as a consequence of general full living and 
sedentary habits, but especially from highly-seasoned and over-cooked 
meats, cheese, pastry, strong acid wines,- &c. ; and the avoidance of 
such articles is a more effectual safeguard against gout, than general 
abstinence, which, in many cases, is absolutely hurtful. Lithic acid is 
one of the lower forms of animal matter into which the higher principles, 
fibrin, albumen, gelatine, &c, tend to pass, in their progress towards dis- 
solution. Hence it is produced in excess, where there is more azotized 
matter than is wanted for the reparation of the textures, or than the vital 
assimilating powers can appropriate for this purpose. But it probably 
results also from the decay of the textures, especially during febrile or 
inflammatory irritation, during and after which copious deposits of the 
lithates are seen in the urine. 

The morbid effects of an excess of lithic acid will vary considerably, 
according to its amount and other circumstances. The kidneys are the 
proper emunctories by which it is eliminated from the blood, and these 
sometimes suffer from the irritation which it causes; hence nephralgia 
and nephritisf may occur: or the water and alkali secreted with it in the 
urine, may be insufficient to hold it in solution, and it may be deposited 
in the form of crystalized sand or gravel, or calculus, in the kidneys or 
bladder; and various irritations and obstructions in the urinary apparatus 
may be the result. 

But sometimes the kidneys may fail in their power of elimination (§ 
170); the lithic acid and its compounds then accumulate in the blood, 
and may cause various irritations and functional derangements, (irregular 
gout, which is extremely common, and of infinitely various form and seat,) 
until at length some circumstance may fix the irritation in a limb, and 
a fit of regular gout is the consequence. In this fit, if perfect, inflamma- 
tion is excited with more or less febrile disturbance, which ends with a 
copious deposit in the urine, showing the removal of the morbid matter 
(§ 165). The more acute and fixed the inflammation, and the smarter 

* This view, although generally admitted on inferential evidence, has lately, for the first 
time, received a demonstration of its truth, in the case of a gouty patient of mine at the 
hospital, in whose blood Dr. Garrod readily detected the presence of lithic acid. The case 
was one of chronic gout; and further illustrated the pathology of the disease, by a total 
absence of lithic acid in the urine, until during the exhibition of colchicum, when its charac- 
teristic crystals appeared under the microscope. 

•}• I have in several instances found in the cortical and tubular structure of the kidney, 
clustered crystals of lithic acid, which, under the microscope, exhibited such sharp angles 
and dagger-shaped projections, as would afford an easy explanation of the pain, inflamma- 
tion, and hemorrhage, often attendant on an attack of renal gravel, even when none is 
obvious in the urine. 



CHANGES IN THE BLOOD — BY TRANSFORMATION. 



131 



the fever, the more abundant is the deposit, and the more free is the 
patient from disease afterwards. On the other hand, when the inflam- 
mation is low, changing its place, and with little fever, it generally 
tarries long, and the system is not relieved. It is when gout thus lasts 
longj or frequently recurs, that often its material so accumulates in the 
joints as to be deposited in the form of a plastery or calculous matter, 
consisting of lithate of soda (chalk stones of gout).* This chronic form 
of gout is connected with a more or less permanent disorder of the diges- 
tive or assimilative functions, which renders its treatment more difficult 
or less successful than that of the more acute forms of gout. In such 
cases (chronic), lithic acid seems to be engendered in great abundance, 
and although thrown off in large quantities in the urine for an indefinite 
period, yet never leaves the body free. Such cases are commonly either 
hereditary, or those which have been rendered inveterate by intemperate 
habits, or neglect of proper treatment. 

255. In saccharine diabetes, the morbid matter is of a nature quite 
contrasted with that of gout and gravel, being grape sugar, which is 
wholly unazotized ; yet this is also probably produced in connection with 
the processes of digestion and assimilation — the condition of the urine 
being only a consequence of disorder in these processes. The analyses 
of Ambrosiani, Maitland, and others, have proved the existence of sugar 
in the blood of diabetic patients, the specific gravity of the serum of 
which may rise to 1060 from its presence; and Macgregor has also es- 
tablished the fact of its unusual production during the process of diges- 
tion. The facility with which, in the laboratory, starch and gum can be 
converted into sugar, especially under the action of acids, throw T s much 
light on the origin of sugar in diabetes ; and the actual presence of a 
very large amount of acid in the stomach in diabetic patients confirms 
this mode of explanation. The appearance of sugar in the urine can 
scarcely be considered otherwise than as a result of its presence in the 
blood. But it is probably formed not only from isomeric principles in 
the food, such as starch and gum, but in confirmed cases it is also derived 
from a decay of the textures, especially the gelatinous, by a modification 
of the process in which urea is naturally evolved, as it has been found 
practicable to convert gelatine partially into glucocol, which has saccha- 
rine properties, and probably consists of sugar and urea. As there is 
saccharine matter naturally in chyle, (and even in blood for a short time 
after the chyle is added to it,) it might be supposed that there is, in in- 
cipient diabetes, an exaggeration of the process by which saccharine 
matter is formed ; and this is countenanced by the fact ascertained by 
Bouchard at, that the sugar* in the blood of diabetic patients is at its 
maximum during the process of chylification, and that it almost disap- 
pears after a long fast.f It is therefore probable that the atrophy and 

* A case of chronic gout at present (June, 1847), under my care, has afforded an oppor- 
tunity of verifying this observation: the matter obtained by puncturing the white tumors of 
his fingers, is of the consistence of thick cream, and consists of very fine acicular crystals of 
lithate of soda, with a trace of lime. 

f [The contradictory results obtained with regard to the presence of sugar in the blood of 
diabetic patients, is due, chiefly, according to 3VL Bouchardat, to the following circumstance. 
If you examine diabetic urine at different periods of the day, you will find that an hour or 
two after meals, it is abundantly secreted, contains a considerable proportion of sugar, which 



132 



ULTIMATE ELEMENTS OF DISEASE. 



cachexia accompanying the disease, result from the draining away of the 
nourishment of the body with the excess of sugar, rather than the con- 
version of all this nourishment into sugar. It is now well ascertained 
that the ordinary animal constituents of the urine are not only present, 
but are often increased considerably beyond their natural amount. 

256. There is a parallel between the indications of treatment in gout 
and in diabetes, although in the fulfilment of these indications, the means 
to be employed are most opposite. In both cases, we must withhold 
those articles of diet from which the morbific matter is most readily 
generated. Thus abstinence from animal food and stimulating condi- 
ments and beverages, in the case of gout — the exclusive use of these 
very articles, to the avoidance of all saccharine or amylaceous substances 
in the case of diabetes — constitute a successful part of the treatment. In 
both cases, it is indicated to improve those processes of digestion and 
assimilation from a perversion of which the morbid matter is probably 
generated. But, unfortunately, we know too little of these processes, 
and of means which may influence them, to enable us to fulfil this indi- 
cation with certainty. A gouty constitution, in the absence of the febrile 
paroxysms, is often much corrected by the use of bitters and other mild 
tonics ; and in diabetes, an amendment occasionally takes place during 
the exhibition of opium and some of the stronger astringents and tonics, 
such as preparations of iron, copper, &c. In both gout and diabetes, the 
mal-assimilation seems to be connected with an unusual development of 
acidity in the system, and in both diseases alkalies have been found to 
be useful; and for reasons presently to be mentioned, soda and potass 
are more suited to gout, and ammonia and magnesia or the alkaline phos- 
phate of soda, succeed best in diabetes. To take full effect, alkalies 
must be given largely in the form of their carbonates. 

In the effect which each exerts on the economy, there is a great differ- 
ence between the morbid matter of gout and that of diabetes. The 
sugar in the latter has no tendency to accumulate in the system and pro- 
duce local effects; but, acting as a powerful diuretic, it passes rapidly 
away, carrying with it a great quantity of water and of the other con- 
stituents of ordinary urine (§ 165); and the thirst, dry skin, and emacia- 
tion of diabetes, seem to be chiefly due to this mode of operation. The 
common complication of diabetes with pulmonary consumption shows 
also, however, that the plastic process is degraded (§ 211). 

The lithic acid of gout and gravel, on the other hand, has a tendency 
to accumulate in the body, and to cause the local and general irritations 
which have been already mentioned (§ 254).- Hence it becomes a chief 

successively decreases for the next twelve or fifteen hours : beyond this term, if the patient 
has eaten nothing, no trace of sugar will be found in the urine. Patients are ordinarily in 
hospitals bled in the morning, the period most distant from their meals, and the amount of 
sugar then in the blood is so minute as to escape detection. By two comparative analyses, 
M. Bouchardat sustains his position. In a patient bled at nine o'clock in the morning, who 
had fasted since five o'clock the previous evening, no trace of sugar was detected. In an- 
other patient bled two hours after a light breakfast, there was unequivocal evidence of sugar 
in the blood. These observations of M. Bouchardat have been corroborated by Simon (a). 
-C] 



(a) Animal Chemistry, p. 267, Amer. Ed. 



CHANGES IN THE BLOOD — BY TRANSFORMATION. 



133 



indication to counteract its irritating properties, and to promote its elimi- 
nation from the system. The medicines which are most efficacious in 
doing this are alkalies, or their carbonates, or their vegetable salts, with 
colchicum, or iodide of potassium, saline mineral waters, and alterative 
aperients. These all increase the action of the kidneys and intestinal 
canal, and drain off the offending matter from the system ; but the ope- 
ration of colchicum is far more certain than that of the others; and its 
permanent efficacy depends on its continued action on the kidneys in 
particular. 

257. It is supposed by most chemists, that the urea excreted by the 
kidneys is chiefly derived from the transformation or decay of the textures 
of the body (§ 254), most of their carbonaceous matter being abstracted 
by the affinity of the oxygen of the blood, and carried off by the lungs 
in the form of carbonic acid gas (§ 232). The causes which increase 
the production of urea are, according to Liebig, those which excite the 
activity of the function of respiration, which supplies the consuming 
oxygen, especially active bodily exercise. Under some circumstances, 
however, the formation and excretion of urea are much augmented, with- 
out any obvious excitement of the respiratory function. This is the case 
in the diabetes ureosus described by Dr. Prout, and which he considers 
a forerunner of saccharine diabetes. Such spontaneous production of 
the matter which seems to be a kind of debris of the body, indicates or- 
ganic debility, or exhaustion of the vital powers, and has been observed 
to occur in young persons who have grown rapidly, or in those weakened 
by great mental exertion and want of sleep, or by venereal excesses. 
An excessive excretion of urea, (or of carbonate of ammonia, which is 
of kindred composition), sometimes takes place in typhoid fevers, and 
is attended with great loss of flesh and strength. A great and sudden 
increase of urea in the urine was ascertained to have taken place, in 
some patients with acute rheumatism, and others with delirium tremens, 
in University College Hospital, at the decline of the fever and other acute 
symptoms. This perhaps ought to be viewed as arising from the removal 
of that which had accumulated, rather than from an increased formation 
of urea; and this fact may be connected with that ascertained by Pro- 
fessor Chelius and Dr. Lewins, that colchicum causes an augmented dis- 
charge of this and other principles of the urine (§§ 252, 173). 

In cases of excessive formation of urea, all circumstances which de- 
press or exhaust the organic life must be avoided, such as great excite- 
ment of body or mind; waste must be supplied by a generous diet,, and 
the nutritive function sustained by tonics. Opium and other narcotics 
are found to be useful in reducing the urine in the diabetes ureosus; and 
they probably operate by calming exhausting nervous excitement, and 
procuring sleep. 

258. The eduction or production of fat from food takes place with 
remarkable activity in some persons ; and wherever it obstructs or su- 
persedes the proper formation of fibrin and other protein principles more 
immediately concerned in giving strength to the bodily frame, it amounts 
to disease. The circumstances in the diet tending to this result, have 



ULTIMATE ELEMENTS OF DISEASE. 



been formerly noticed (§§ 59, 60), and we have had occasion to mention 
that sedentary habits and a lowered condition of the respiratory function, 
have sometimes a similar effect (§§ 239, 65). Bat in connection with 
our present subject, there are many reasons for supposing that an exces- 
sive production of fat sometimes occurs as an error in assimilation, and 
may interfere with the sufficient production of other animal principles, 
and with the nourishment of the textures of kindred composition, whilst 
fat accumulates not only in its proper texture, but invades others, low- 
ering their vitality and cohesion, and thus constituting a cause of gra- 
dual degeneration. Thus Mr. Gulliver has shown that the atheromatous 
patches in the coats of arteries, which appear to be a mark of declining 
age, (natural or premature,) are of the nature of fatty degeneration. The 
same pathologist has discovered a predominance of fatty matter (chiefly 
olein, margarin, and cholesterin), in the lungs, the kidneys, and testicles, 
under various chronic diseases. (Med. Gazette, June 1843.) A similar 
abundance of fat has been frequently observed by me (first in conjunction 
with Dr. R. Quain, in May, 1845), in the kidneys, liver, and other struc- 
tures of persons whose habits of excessive intemperance proved fatal, with 
symptoms of general cachexia and failure of many functions. This 
subject will be noticed again under the head of perverted nutrition, where 
the remedies to be opposed to the element, fatty transformation, will be 
considered. 



SECTION XVI. 

CHANGED PROPERTIES OF THE BLOOD FROM THE PRESENCE OF FOREIGN 

MATTERS. 

259. The blood is probably the chief seat of the morbid poisons which 
excite various contagious (§ 93), epidemic (§ 88), and endemic diseases 
(§ 81). Probably, too, it is the hotbed in which some of them are pro- 
pagated, whether by seeds, ova, cell-germs, or parasites (§ 99); and it is 
through changes in its composition that many of the destructive effects 
of these poisons are produced (§§ 186, 196). We have already noticed 
some of these changes under former heads. It will suffice in this place 
to mention a few examples in which morbid poisons have been traced to 
the blood. 

Dr. Francis Home communicated measles from one person to another 
by inoculating with the blood of a patient affected with the disease. M. 
Gendrin describes the following experiment : — A man who had been skin- 
ning a diseased animal was seized with a putrid fever, attended with an 
eruption of sloughing pustules. Some blood taken from this man w T as 
injected into the cellular texture of the groin of a cat; the animal was 
soon affected with vomiting of bile, dyspnoea, frequent, small, and irre- 
gular pulse, dry brown tongue, slight convulsions, and died seven hours 
after the injection. The same pathologist produced in animals various 



CHANGES IN THE BLOOD BY FOREIGN MATTERS. 



135 



severe symptoms, speedily ending in death, by injecting into their veins 
blood from a person laboring under confluent small-pox. MM. Dupuy 
and Leuret communicated to a healthy horse the malignant pustular dis- 
ease called "charbon," by injecting into its veins blood from a diseased 
animal; and M. Renault, in a similar way, propagated glanders from one 
horse to another. Andral quotes from Duhamel an extraordinary case, in 
which blistering, pustules, malignant fever, and death, followed the mere 
contact on the lips of the diseased blood of an animal. Other instances 
are on record of sickness, faintness, and serious illness being caused by 
the odor of blood; and Dr. Copland quotes from Zacutus a marvelous 
story of three persons being struck dead by the smell of the blood of a 
patient in the plague. 

There is good reason to suppose that purulent matter, and the germs 
(§ 90) of carcinoma, and other forms of malignant disease, are spread 
through the system through the medium of the blood. Pus has been 
frequently detected in the blood by the aid of the microscope, first by 
Mr. Gulliver, and by many subsequent observers. The pus globule is 
to be distinguished from the pale or lymph corpuscle, by its somewhat 
larger size, more distinct and often granular cell-wall, by its contained 
granules or nuclei being more distinct, and sometimes loose in its interior ; 
and lastly, by its exhibiting exosmotic and endosmotic properties much 
more actively. The different effects of pus in the blood will be noticed 
under the head of results of inflammation. The tendency to symmetrical 
arrangement which cutaneous eruptions, nodosities of the joints, paraly- 
sis from lead, and some other local affections, exhibit, has been adduced, 
by Dr. W. Budd and others, as an instance of effects produced through 
the medium of the blood — the symmetrical distribution of this fluid on 
the opposite halves of the body leading to like results in corresponding 
parts. 

260. In the treatment of this element of disease, foreign morbific mat- 
ters in the blood, the two indications which present themselves are — 1. 
To counteract the injurious operation of these matters; and, 2. To expel 
them from the system. The first of these indications is followed, when 
we give stimulants to overcome the depressing influence of adynamic 
fevers and other sedative poisons ; anti-periodic tonics to prevent the ope- 
ration of the paludal poison (§ 81); and when opium and other narcotics 
are administered where irritation prevails. We do not possess chemical 
antidotes which can act on the foreign matter in the blood without in- 
juring the blood itself. The other indication is more generally pursued, 
although little recognized by practitioners, — to expel the offending mat- 
ter from the system. The excretory organs, especially the kidneys and 
alimentary canal, are the natural emunctories through which foreign and 
offending matters are expelled from the blood ; and hence the utility of 
alterative aperients and diuretics (§§ 173, 174), in the treatment of fever 
and other diseases connected with poison or injurious matter in the blood. 
Orfila found that the pernicious effects of small repeated doses of arsenic 
in animals might be averted by giving, at the same time, a diuretic medi- 
cine. Let us bear in mind how often fevers and other serious ailments 
seem to be carried off by spontaneous diarrhoea, diuresis, or perspiration ; 



136 



ULTIMATE ELEMENTS OF DISEASE. 



and, perhaps, sometimes by these discharges artificially excited. Nor 
should a converse fact be overlooked, that persons affected with diseases 
of the kidney, which impair its excernent function, are peculiarly liable 
to contract infectious diseases, and to suffer from their effects (§§ 17, 26, 
32). Similar observations maybe made respecting various other poisons 
which operate through the blood, such as opium, arsenic, mercury, &c, 
which operate with uncommon, and therefore dangerous energy, on those 
whose excreting functions are much impaired. 



137 



CHAPTER III. 

SECONDARY OR PROXIMATE ELEMENTS OF DISEASE, CONSISTING OF TWO 
OR MORE PRIMARY ELEMENTS (§ 304). 



SECTION I. 

ANiEMIA. 

261. The class of proximate elements which have been most generally 
studied as the subjects of general pathology, are those affecting the cir- 
culation of the blood. They comprise at least three of the primary 
elements which have been considered — the blood and its constituents, 
the irritability and the tonicity of the organs (§§ 110, 120), concerned 
in its distribution. A previous acquaintance with these elements will 
render very intelligible many of the kinds and phenomena of their com- 
pounds, but it is necessary to keep in view also the physical properties 
of the vessels and their contents ; for these properties, when altered, 
become elements of disease. Thus a mechanical obstruction or an 
enlargement of a blood-vessel contributes to the formation of disease as 
much as a change of vital properties. So it is impossible to understand 
the effects of too much or too little blood in the vessels, without a due 
consideration of the mechanism of the circulation. 

We shall briefly consider the morbid conditions connected with defect 
and excess of blood in the vessels, under the divisions of general and 
partial, and as attended with an increase or diminution of the irritability 
and tone of the moving fibre. It is to be understood that all the proximate 
elements of disease now to be considered, may occur either as distinct 
affections or in combination with other maladies. 

262. Anaemia, or as it has been more correctly termed, hypcemia, or 
aligcemia, is the name applied to that condition of the system in which 
the predominant character is a deficiency of blood. And as, together 
with this deficiency in quantity, there is very generally a remarkable 
deterioration in its quality, the late Dr. Simon applied to the condition 
the term spansemia (octavos, poor). 

263. The exciting causes of ansemia are, various circumstances which 
withdraw or injure the blood, especially the red particles (§ 71), or inter- 
fere with their formation (§ 66); such as excessive bleedings, or hemor- 
rhages ; profuse evacuations of other fluids which contain much of the 



138 



PROXIMATE ELEMENTS OF DISEASE. 



animal parts of the blood ; scanty or poor food, especially that which 
contains little animal matter or protein; confinement in impure air, dark 
places, or malarious districts (§ 191) ; certain chronic maladies which 
deeply affect the constitution, such as tuberculous and cancerous dis- 
eases, and granular degenerations of the kidneys (§§ 185, 2.22,249); 
but the commonest cause of all is irregularity of the uterine function, 
which induces the common form of the disease long familiar under the 
designation chlorosis. It might seem difficult to understand how the 
last operates; but that, in many cases, it is a cause and not an effect of 
anaemia, is plain from the well-known fact that no signs of anaemia have 
occurred until cold, over-exertion, or mental excitement, or some cir- 
cumstance, has suddenly checked the flow of the catamenia; it has not 
returned; and then the patient begins to lose color, and gradually to 
exhibit the anaemic state. In many cases, I have known this occur in 
young females who have previously suffered from acute rheumatism, im- 
plicating the heart. It would seem that, in these cases, some injury is 
done to the blood particles, and to the powers by which they are repaired : 
this is manifest not only from the pallidity, but from the yellowish and 
almost greenish hue which the complexion sometimes presents, and 
which obviously depends on a discoloration of the textures by the altered 
blood, as in the neighborhood of a bruised part. The nature of these 
changes has been already noticed (§§ 185-6, 191). In some of these 
cases of chlorosis, the appetite is depraved (§ 131); there is such a com- 
plete disrelish for animal food and other nourishing articles, and such a 
craving for sour things, and even for matters destitute of nourishment, 
as chalk, cinders, &c, that it might be supposed that this perverted ap- 
petite is the cause of the anaemia, by deterring the patient from taking 
that food which is capable of making red blood; and undoubtedly such 
an appetite, when indulged, must contribute to this result ; but it is not 
so constantly present as to be considered the chief cause of the anaemia 
in the examples under consideration. 

It is often symptomatic of various maladies, particularly chronic and 
cachectic affections; but it sometimes occurs without any other known 
disease, and its symptoms exemplify in a striking manner the mode in 
which the various functions suffer for want of a due supply of the vivify- 
ing fluid (§§ 183, 185). 

Thus the general symptoms of anaemia are those of weakness (§ 116); 
general muscular weakness, evinced by the faintness, breathlessness, 
and fatigue caused by exercise; weakness of the heart, shown by the 
feeble, loose, or thready pulse, rendered very frequent and palpitating 
by slight exertion, and often irregular and failing afterwards; feebleness 
of the whole circulation (§ 123), manifest in the coldness of the surface 
and extremities ; organic weakness, shown by the loss of appetite, indi- 
gestion, torpor of the bowels, scanty and disordered secretions (§ 172); 
defective nutrition (§ 211), especially of the muscular parts; and imper- 
fect sanguification, for the remaining blood becomes diseased, being 
poor and watery, as well as scanty (§§ 185, 222). 

264. There are also distinctive physical signs of the scantiness of blood 
in the body : the surface is remarkably pallid, and even the lips, gums, 
and tongue, show none of their healthy ruddiness. The complexion 



ANAEMIA. 



139 



may vary the amount and kind of the paleness, dark persons often ap- 
pearing very sallow, or even of a yellowish or greenish tint, and those 
of fair complexion having a ghostly paleness. If blood-vessels are seen 
at all, it is only the larger superficial veins, which are pink instead of 
blue, from the paucity and transparency of the blood in them. In the 
course of the larger veins, especially the jugulars in the neck, the thin 
blood, running with great rapidity in the ill-filled vessels, is often thrown 
into sonorous vibrations (venous murmurs), which are sometimes sensible 
to the finger placed lightly on the vein. The same thinness of the blood, 
together with an abruptness in the heart's contractions (§ 113), frequently 
causes a murmur with the first sound of the heart, referable to the aortic 
orifice; as, however, this murmur varies much in different cases, being 
scarcely audible in some, whilst it is loud and harsh in others, it is ob- 
viously dependent in part on some irregularity or narrowing at the mouth 
of the aorta, too trifling to give any obstruction or sound when the blood 
is abundant and of due spissitude, but readily causing vibrations and 
sonorous gushes when the fluid is thin, and the relations between the size 
of the heart and arteries somewhat changed. 

265. The blood, when drawn, is very thin and watery. It readily coagu- 
lates, and forms a very small contracted clot (§ 207), generally covered 
with a bufFy coat. This appearance is probably due, as Andral surmises, 
to a predominance of the fibrin over the red particles, for these are di- 
minished much more than the fibrin, being, in extreme cases, reduced 
to one-fifth of their natural proportion (§ 185). The albumen is also 
generally scantier than usual; a remarkable exception in the ansemia 
attendant on paraplegia has been already noticed (§ 221). 

266. Although the symptoms of ansemia are chiefly those of great 
weakness or depression (§ 262), there are often others of an opposite cha- 
racter, indicating irritation or exaltation of function. Some of these 
arise indirectly from the weakness, as, for example, pain in the left side 
and epigastrium, nausea, colic and diarrhoea (§§ 56, 168, &c), which 
may be traced to the weak digestion leading to the production of sundry 
irritating matters, from that which has been used for nourishment. But 
other more direct signs of excitement sometimes occur. Thus various 
properties of the nervous system are sometimes exalted ; sensibility is 
acute (§ 126); there is intolerance of light and sound, w T ith flashes in 
the eyes, noise in the ears, a sense of rushing in the head, and various 
neuralgic pains. The excito-motory nerves are sometimes excited (§§ 
140, 150), and spasms, or convulsive affections of different kinds, may 
be present, or the organic functions may be affected, and palpitation, 
spasmodic asthma, vomiting, and such sympathetic irritations, may oc- 
cur. In a few instances, ansemia has been attended with delirium, or 
mental excitement bordering on it. 

267. It thus appears that the functions which frequently are thus ex- 
cited in the midst of general depression and weakness, are those of the 
nervous centres ; and the generally nervous character of persons in a 
state of great weakness (§ 113), is connected with the same fact, so that 
nervousness and weakness are almost synonymous terms. No explana- 
tion of this apparent anomaly has been, to my knowledge, proposed ; 
but one seems to suggest itself in the peculiar distribution of the circu- 



140 



PROXIMATE ELEMENTS OF DISEASE. 



lation through the nervous centres. When the mass of the blood is re- 
duced in quantity, the blood-vessels generally contract in proportion, 
their tonicity adapting them to the amount of their contents (§ 120). But 
the vessels within the skull and spinal canal cannot contract with the 
same facility, for not being exposed to atmospheric pressure, and some 
of them being fixed in bony canals, they do not shrink as the blood be- 
comes reduced, and, therefore, they retain more than their proper share 
of the circulating fluid.* This disproportionate amount of blood in the 
nervous centres, produces different effects, according to the degree in 
which the heart's propulsive power (§111) reaches it. Under the influ- 
ence of temporary palpitation (§ 112), fever, or other kind of excitement, 
the brain and spinal cord, through their uncontracted vessels which are 
among the nearest to the heart, receive a usual share of its exalted but 
partial force ; an erethism of some one or more of the functions of these 
nervous centres (§§ 127, 133, 153) is the consequence ; and pain, spasm, 
sensorial excitement, intolerance of light and sound, or sympathetic irri- 
tations of some kind or another, occur. f In this condition, the head 
may be hot and throbbing, the face flushed, the eyes suffused, whilst the 
extremities and the surface generally are comparatively bloodless, and 
either cold, or very speedily becoming so, on exposure. Epistaxis some- 
times occurs, and although bringing momentary relief, may, if consider- 
able, add to the evil, by increasing the anaemia. 

268. On the other hand, if the heart's action is feeble (§ 116), it may 
be inadequate to propel the blood accumulated in the vessels of the brain: 
it therefore stagnates, and may cause some of the symptoms of congestion 
in that organ. Hence headache and giddiness, relieved by the recum- 
bent posture, drowsiness, impaired mental faculties, obscured vision and 
hearing, partial paralysis, and, in extreme cases, coma or catalepsy 
(§§ 129, 133, 141). In such cases, the blood is accumulated more in the 
veins and sinuses of the brain than in its arteries, and not receiving 
enough force from the heart to keep it in full motion, it partially stagnates, 
and the functions of the corresponding parts are impaired in proportion. 
This congestion may be only temporary, and lead to no serious results; 
but in some cases I believe there occurs an event that has not been no- 
ticed by pathologists — namely, a coagulation of the blood in the sinuses, 
and a consequent permanent obstruction to the passage of the blood 

* This statement is not invalidated by the recent experiments of Dr. G. Burrows, (Med. 
Gaz., April, 1843, [Disorders of the Cerebral Circulation, fyc. fyc, Phil., 1848.]) His experi- 
ments and expositions very satisfactorily demonstrate the absurdity of the notions, founded 
on Dr. Kellie's paper, that the quantity of blood in the head is always the same ; but it re- 
mains clear, that the circulation within the head and spinal canal, especially in man, is 
affected by losses of blood differently from the circulation in other parts. 

j- Although the chief effect of excitement of the circulation in anaemia is thus directed to 
the nervous centres, it is by no means confined to them. Other parts, in the immediate vi- 
cinity of the heart, become the seat of increased arterial yjulsation and disturbance. Thus, 
a painful throbbing is often complained of in the throat, chest and epigastrium, even when 
there is little pulse in distant arteries, and the extremities are cold. To understand these 
facts, we must bear in mind that when the arteries are full and tense, they oppose their full- 
ness and tension to each contraction of the heart, which resistance reduces the strength of 
each pulse in the vicinity of the heart, although it continues to propagate it to a distance; 
but when the arteries are empty and loose, the heart squirts into them the blood in an un- 
resisted jet, the force of which is strong near the heart, but extends not to distant arteries. 



ANAEMIA. 



141 



through the brain. I have met with several cases more or less corre- 
sponding with the following description. 

A young female becomes anaemic, and after exhibiting various symp- 
toms of feeble general circulation, with headache, drowsiness, and im- 
paired sensorial functions, suddenly becomes worse ; passes into a state 
of stupor with dilated pupils, sometimes varied by slight manifestations 
of delirium, throbbing of the carotids, and partial heat of the head, and 
dies comatose. On opening the head, a small quantity of serum is found 
under the arachnoid and in the ventricles, sometimes with a little lymph 
(in one case there was none). The vascularity of the membranes is re- 
markable, but the vessels most distended are the veins, and in the larger 
of these and in the longitudinal sinus, there is a firm coagulum. In 
parts, especially at the torcular Herophili, this coagulum blocks the whole 
sinus, and exhibits a separation of fibrin, portions of which are softened 
down into that opaque purilaginous matter which was long mistaken for 
pus, but which Mr. Gulliver has shown to be a mere disintegration of 
the fibrin w T hich mere stagnation in a w r arm temperature may effect. 
These have been taken for cases of meningitis. No doubt inflammation 
may supervene in them occasionally, but in two cases that have fallen 
under my notice, there was no adhesion of the arachnoid nor deposit 
upon it, nor any other unequivocal mark of inflammatory action ; yet the 
fibrinous and bloody concretions in the veins and sinuses were most re- 
markable for their size and firmness* (§ 213). 

It appears to me most probable that these affections originate in the 
encephalic congestion connected with anaemia. Fibrinous concretions 
form on the transverse bands of the sinuses, and increase until they con- 
siderably obstruct the passage of the blood: hence the impaired state of 
the cerebral functions, amounting at last to coma. Reaction (§ 16) may 
take place, with determination of blood, and even inflammation, and 
these cause those symptoms of partial excitement that sometimes exhibit 
themselves; but neither during life nor on examination after death, are 
the proofs of excitement so prominent as those of obstruction and inter- 
ruption to the cerebral functions. It must be remembered that in ansemia 
the fibrin of the blood is not diminished in the proportion of the other 
animal contents, and it has a greater tendency to coagulate than in 
healthy blood (§ 207). 

269. In ansemia of long duration, the process of nutrition often suffers 
(§ 211), but by no means uniformly. The cornea sometimes becomes 
ulcerated ; probably because, being a non-vascular texture, it the more 
needs a nourishing quality of the plasma. The muscles become flabby 
and attenuated ; w^ounds and fractures sometimes do not readily unite ; 
and in some instances spreading ulcers and sloughy sores form spon- 
taneously on the surface. Emaciation is by no means a constant result 
of anaemia; and it is not uncommon to see the most pallid subjects, 
especially females, retain a considerable amount of fat. Dropsical ef- 
fusion into the cellular texture is a common result of anaemia, when either 

* A wax model of the sinuses and membranes in one of these cases, is in the museum at 
the University College. Cruveilhier gives a representation of a similar case, which, with- 
out sufficient reason, he considers as one of cerebral phlebitis. Andral mentions a case of 
cerebral hemorrhage in connection with anaemia, which was probably of the same kind. 



142 



PROXIMATE ELEMENTS OF DISEASE. 



long continued, or aggravated by additional causes which disturb the 
circulation (§ 222). The researches of Chossat on the effects of inanition 
on animals, are in some measure applicable to this subject; for anaemia 
is the result of deficient food (§ 63). He found that defective nourish- 
ment notably reduced the weight of all the structures of the body, except 
only those of the -nervous system, which were wonderfully little dimi- 
nished by it. This fact accords with that of the remarkably predominant 
activity of this system in persons weakened by low diet and similar causes ; 
and is well explained by the manner in which the vessels supplying the 
nervous centres' monopolize the blood, as indicated in a preceding para- 
graph (§ 267). Hence this ascendancy of nervous function, which was 
first a temporary result of irregular circulation, becomes in time perma- 
nent from comparative change of structure; and the condition which at 
first might have been obviated by means which regulate the flow of blood, 
assumes the fixedness and intractability of structural disease. 

270. Anaemia, in its extreme degrees, may prove fatal suddenly by 
syncope (§ 71), brought on by exertion, or any additional cause of ex- 
haustion ; or, more gradually, by asthenia, or general failure of the vital 
powers, often attended with anasarca; or, by developing tuberculous 
(§ 211) or other cachectic diseases, to which the individual may be pre- 
disposed; by the singular affection of the head before noticed (§ 267), 
or by slower and less marked changes in the nervous centres ; leading 
to paralysis, insanity, amentia, epilepsy. 

[The fundamental and constant character of anaemia, is the diminu- 
tion in the red corpuscles of the blood. Women are more subject to it 
than men, although these may be attacked with spontaneous anaemia at 
all ages. The clot is small, but firm and dense, swims in a large quan- 
tity of colorless serum, and presents on its surface a well-marked buffy 
coat, which, however, differs from the buff of inflammatory blood, by a 
gradual termination in the red mass, and not by an abrupt, well-defined 
line. (This is due to the excess of fibrin relatively to the globules.) When 
the red corpuscles are below 80, according to Andral, the bruit de soufflet 
in the arteries is a constant phenomenon. It is often heard, when their 
cypher oscillates between 80 and 100, and becomes more rare as the 
physiological mean is approached, and when it is reached, ceases alto- 
gether. Whatever other disease, besides anaemia, in which this dimi- 
nution of the red corpuscles exists, we have this phenomenon ; in putrid 
and eruptive fevers, pneumonias, acute articular rheumatism, and in a 
great variety of chronic diseases. The bruit de soufflet is often present 
in pregnant women, and corresponds with the frequent diminution of the 
red globules in them. 

In spontaneous anaemia, the red corpuscles alone are affected, the other 
sanguine elements remaining intact; subsequently, however, they may 
become likewise compromised. — C] 

271. Remedial Measures. — Most of the measures useful for the treat- 
ment of anaemia, have been already described, as those suitable to 
restore a deficiency of red particles, and fibro-albumen (§§ 193, 216). 
A nourishing diet, with as much animal food as the digestive powers of 
the patient can master — tonics that best restore the appetite, the powers 
of digestion, and sanguification — the use of means, if necessary, to 



ANEMIA — TREATMENT. 



143 



promote the natural excretions (§§ 172 et seq., 191), and an exposure 
of the patient to the pure air and light of heaven, as free and as long 
as the strength and sensibility will bear — form the chief items of the 
treatment. 

The adaptation of this treatment to particular cases will require much 
discretion, especially in proportioning the food to the faculty of digestion, 
and in selecting a tonic that shall not irritate. Where it does not dis- 
agree, iron, in some of its forms, is unquestionably the best tonic: and 
in many comparative trials, I have found the iodide of iron, (in solution 
with syrup,) the most speedily efficacious. Besides its tonic action, it 
promotes the secretions more than other combinations of iron, and in 
some way like other preparations of iodine, increases the freedom of the 
capillary circulation : by its use I have seen females restored from ex- 
treme pallidity to a rosy hue of health in less than three weeks. The 
sesquioxide, citrate, tartrate, and ammonio-chloride, are more tardy in 
their operation; and the sulphate and sesquichloride are apt to nauseate,, 
or otherwise disagree ; but each is found occasionally useful, and so are 
chalybeate mineral waters. In some cases, any preparation of iron 
causes headache, fever, sickness, or some other symptoms of disorder; 
and then milder tonics, as columbo, or other bitters, with mineral acids, 
or with iodide of potassium, are more suitable at first ; and the stronger 
tonics, with iron, may be given afterwards. In extreme cases, as those 
after excessive losses of blood, I have found it very useful to give sul- 
phate of quinine at the same time as the iodide, or some preparation of 
iron. 

The success of the treatment becomes manifest, not only in the return 
of a healthy color to the lips and skin, size to the superficial vessels, and 
strength to the pulse, but also by an improvement in all the functions, 
breath, strength, digestion, &c. It is a curious fact, that the venous 
murmurs (§ 263), although diminished, are not so in proportion to the 
apparent return of color to the surface; I have before given reasons for 
considering them to depend on deficiency of albumen, as well as of the 
red particles. This does not accord with the opinion of M. Andral, who 
reckons the vascular murmurs to be a true exponent of the deficiency of 
the red particles only; but this, as a matter of observation, loses weight 
from the erroneous notion which he, in common with Bouillaud, holds 
as to the true seat of these murmurs. They believe them to be in the 
carotids only; I several years since was satisfied, from numerous and 
varied experiments, that Dr. Ogier Ward's opinion, that the loudest mur- 
murs are in the veins, is correct. I may add, that they are to be accu- 
rately investigated only by the flexible ear-tube recommended by Dr. 
Stroud. 

272. Besides these general measures, indicated for all varieties of 
ansemia, particular cases require temporary measures, on the one hand, 
to prevent faintness or excess of weakness (§ 262); on the other, to 
subdue nervous excitement (§ 265), and counteract the congestion in the 
head, which we have found to occur (§ 267). Diffusible stimulants, such 
as carbonate of ammonia, valerian, ether, wine, and spirits, are often 
useful as temporary means of obviating the extreme weakness. Symp- 
toms of nervous excitement (§ 26) require nervous sedatives and nar- 



144 



PROXIMATE ELEMENTS OF DISEASE. 



cotics; such as hydrocyanic acid, hyoscyamus, belladonna, conium, &c; 
whilst those of nervous depression indicate the use of such stimulants 
as are found to excite the nervous energies, such as the fetid gums, oil 
of turpentine, (especially in enema,) strong tea and coffee, cantharides, 
strychnia, electricity, &c. (§§ 130, 155). But, inasmuch as these very 
symptoms seem to depend on the irregular distribution of the little blood 
left in the body, they will be the most effectually relieved by reducing 
this irregularity, by the unremitting maintenance of warmth in the sur- 
face and extremities, aided by occasional friction, rest in the horizontal 
posture, varied with such gentle exercise as the patient can bear; with 
pure air, and the judicious use of tepid or cold sponging, or shower-bath, 
especially directed on the head and spine (§ 124). The symptoms of 
decided cerebral congestion and obstruction have generally been treated 
by antiphlogistic remedies, but with questionable advantage. I have 
found more benefit to result from a mild stimulant and tonic plan, toge- 
ther with more or less powerful derivants, purgatives, and saline diure- 
tics. Such a plan commonly answers best in the congestive headache, 
which often troubles anaemic subjects. Depletion is often earnestly 
called for by the patient; but it should be avoided as much as possible: 
where absolutely required, from the urgency of the symptoms, cupping 
to the nucha, or leeches to the temples, or, what is more effectual, two 
leeches to the interior of the nostrils, will answer best. Persons who 
have long and severely suffered from anaemia, especially from excessive 
and repeated losses of blood, or from menorrhagia or uterine hemorrhage, 
or from inordinate lactation, do not lose their nervous symptoms in pro- 
portion as their blood is restored ; and this I would ascribe to the struc- 
tural change which has ensued, as before described (§ 268). The treat- 
ment necessary in such cases is of a permanent kind, avoiding all causes 
of nervous excitement, and using those various means, medicinal and 
regiminal, which have been formerly recommended as useful in reducing 
nervous excitability (§§ 128, 155). Of the medicines serviceable in 
such cases, the metallic tonics are most deserving of mention ; especially 
the valerianate and sulphate of zinc, the nitrate and oxide of silver, and 
the sulphate of copper. 



PARTIAL ANiEMIA. 

273. We have the means of studying defect of blood in a part of the 
body in more diversified degrees than defect in the whole ; and the result 
we find to be an impaired state of the functions in every degree, from that 
of mere weakness to that of total suspension and death. Thus temporary 
pressure on the chief artery of a limb soon causes numbness, weakness, 
and reduction of temperature. The same effects result in a more marked 
degree from the ligature of an artery in cases of aneurism, and are gra- 
dually removed as the supply of blood is restored through collateral arte- 
ries. In some such cases, the supply of blood is insufficient to maintain 
the vital properties of the part; then chemical affinities prevail (§ 50), 
decomposition ensues, and the part becomes gangrenous, and dies. A 
similar result ensues when the arteries of a limb become obstructed by 
ossification and coagulation, as in senile gangrene. This event may be 



HYPEREMIA. 



145 



produced artificially in animals in forty-eight hours, by injecting charcoal 
powder into the artery of a limb, which totally obstructs its capillaries. 
(Majendie.) It is, most probably, by obstructing the circulation, and thus 
depriving the tissues of an element indispensable for the maintenance 
of their life, that inflammation and other lesions sometimes terminate in 
gangrene. 

Softening and wasting of textures are also effects attributable to con- 
tinued defective supply of blood. The former is exemplified in soften- 
ing of the brain and of the heart in connection with ossified arteries; the 
latter in the wasting of parts subjected to continued pressure. Hence 
partial anemia is concerned in producing many changes of structure aris- 
ing under various circumstances. Deficient supply to secreting organs 
necessarily impairs the amount and quality of their secretions (§ 159). 



SECTION II. 



HYPEREMIA OR POLY-^MIA, EXCESS OF BLOOD, 



274. Too much blood in the system, or in a part, is a most frequent 
element of disease. It implies an undue distention of the vessels which 
contain it • and a modification of the properties of these, and of the 
heart which propels it, is almost constantly a concomitant of this mor- 
bid condition. The chief vital properties of the heart and vessels are 
irritability and tonicity; excess (§§ 114, 121), and defect (§§ 116, 123) 
of these form most important elements, which modify the effects of ex- 
cess of blood : and thus is suggested synthetically a division (long re- 
cognized as most valuable in practice), into active or sthenic, and pas- 
sive or asthenic hypersemia; which distinction is applicable to both the 
general and the partial excess of blood. Another variety of hypersemia 
may be distinguished by an altered or perverted action of the vessels, 
which is chiefly applicable to the affection in a part, and includes that 
singular and complex condition — inflammation. A view of these import- 
ant proximate elements of disease (§ 107) is given in the following table. 
It is not meant that the diseased conditions here specified are always se- 
parate, or that they consist merely of the elements here stated; but these 
are their most distinguishing parts, and most important in regard to treat- 
ment. 



General = Plethora 



HXPER- 
.33MIA 

Excess of 
blood. 



10 



with motion increased = Sthenic 



diminished = Asthenic 



Results. 



Local ■ 



with motion diminished = Congestion 

— — increased = Determination of blood 

— — partly increased, 

partly diminished = Inflammation, 




146 



PROXIMATE ELEMENTS OF DISEASE. 



SECTION III. 

PLETHORA GENERAL EXCESS OF BLOOD. 

275. As general anaemia may arise from defective formation or exces- 
sive expenditure of blood, so general plethora may proceed either from 
too much blood being made, or from too little being expended. In 
either case, the blood accumulates and fills the heart and blood-vessels 
beyond the usual degree. But this implies a certain activity and health 
in the processes of digestion and assimilation, and also a freedom from 
any considerable local disorder. A person with weak digestion, rarely 
becomes plethoric; and one who suffers from a local ailment, is com- 
monly warned by an aggravation of this, before the fullness can become 
general. 

276. The persons who become plethoric are rather those overflowing 
with health, w r ho have a good appetite, and indulge it, without sufficient 
regard to exercise and to the excernent functions ; and whose digestive 
powers are in full activity. The blood-making process is ever on the 
increase, the vessels becoming more and more rilled ; and their fullness 
becomes manifest in the red face, distended veins, and full pulse; the 
heart is excited, and labors w T ith its load, especially on exertion; hence 
palpitation and short breath may ensue, w T ith somnolency and indisposi- 
tion to exertion ; but these may attract no further notice than to induce 
the abandonment of exercise. The state of plethora, thus gradually in- 
duced, may be extreme, without any functions materially failing, and 
yet the subject is on the brink of various maladies. It is well if a great 
secreting organ is first excited under the high pressure, and relieves the 
system through a free discharge, as by mucous or bilious diarrhoea ; or 
some unimportant and convenient set of blood-vessels may give way, as 
in epistaxis, or bleeding piles, &c. ; or one of the great secreting organs 
may fail in its proper function (§§ 170, 254), as the liver or the kid- 
neys; and a bilious attack, jaundice, or a fit of gout or gravel, is the 
consequence. Any of these, by establishing a perceptible ailment, dis- 
turbs the dangerous ease of the plethoric ; and by rendering necessary 
a temporary discipline, saves him from the worst results of plethora — 
apoplexy, structural disease of the heart, great vessels, lungs, kidneys, 
or liver. 

277. Besides the causes already noticed, other circumstances may 
induce plethora. The diminution of a natural or habitual excretion or 
loss of blood, the drying- up of a long-established sore or issue (§ 270), 
or the removal of a limb ; all of which diminish the expenditure from the 
system, without impairing the blood-making process, often become causes 
of plethora, if no local disorder be excited before the vessels in general 
reach a plethoric tension. 

278. The division of plethora into sthenic and asthenic arises from dif- 



GENERAL PLETHORA. 



147 



ferent proportions of the strength and irritability of the moving fibre, 
which we have noticed as ultimate elements of disease (§§ 110 and 120, 
et seq.). Where the irritability and tone of the heart and arteries are in 
full amount, the increased quantity of blood excites these properties to 
full operation. Short of disease, the functions are active and energetic 
in proportion to the quantity of blood which their organs receive ; the 
heart's action and the arterial pulse are strong and regular ; secretions 
are abundant, sensibility is keen, contractility powerful and in good tone, 
animal heat is sustained, and the mental and bodily powers generally are 
great and active. But beyond this, plethora tends to disease ; the heart's 
action is over excited ; the pulse is frequent, as well as strong and hard ; 
the face is florid and flushed, and the heat is almost feverish ; the capil- 
laries of secreting organs and surfaces are variously disordered ; some- 
times excited to excessive secretion, sometimes beyond it, to a state of 
fullness bordering on hemorrhage or inflammation ; hence occur bilious 
attacks, hematemesis, lithic acid gravel, strong and acid urine, and vari- 
ous forms of sthenic gout: the sensibility and sensorial powers may be 
over excited by the rapid flow, or oppressed by the pressure of the blood 
on the nervous centres. If the plethoric state is moderate enough to last 
for some time without immediate disaster, the nutritive function will 
eventually be affected. Some of the superfluous nourishment may be- 
come deposited in fat, which is another safety valve to the plethoric : but 
even this throws an additional burden on the heart and blood-vessels, 
which are the more strained and oppressed, and are among the first of 
the textures to exhibit textural changes, in hypertrophy, valvular dis- 
ease, aneurism, &c. Thus may originate structural disease, from the 
continued excitement of sthenic plethora. 

279. Sthenic plethora is that which commonly affects the young, the 
active, and those of sanguine temperament (§ 41). It comprehends a 
rich state of the blood (§ 184), and an active condition of the nutrient 
function (§ 195). Its tendency is to cause general febrile excitement, 
active hemorrhages, fluxes and inflammations. 

280. In asthenic plethora, there is a want of contractility (§ 116) and 
tone (§ 123) in the moving fibre. The heart and other organs, instead 
of being excited by the augmented quantity of blood, are oppressed by 
its load. The pulse may be full, but it is slow ; sometimes irregular or 
unequal. There is sometimes a tendency to faintness alternating with 
palpitation; physical examination shows the heart to be enlarged by the 
accumulation of its contents, w T hich it cannot expel. The face is purple 
rather than red; the veins are generally distended; sometimes the ex- 
tremities are apt to become cold. Other functions are sluggish, and im- 
perfectly or irregularly carried on. The bowels are torpid, the urine 
scanty, high-colored, or turbid, sensibility is blunted, and the mental 
faculties dull, with lethargy or somnolency, the spirits often depressed, 
and the strength reduced. 

281. Asthenic plethora affects especially those weakened by age, ex- 
cesses, or previous disease, and those in whom the excreting organs act 
imperfectly ; which imperfect action is a cause, as well as a consequence, 
of plethora. Asthenic plethora tends to produce congestions and passive 
hemorrhages, and fluxes and dropsies; and if continued, structural 



148 



PROXIMATE ELEMENTS OF DISEASE. 



changes in some organs, as dilatation of the heart, enlarged liver, vari- 
cose veins, &c. Congestion of the brain, with apoplexy or palsy, head- 
ache, or other symptoms of disturbed function, sometimes is produced ; 
or if there be any organ, the vessels of which, from past or present 
causes (§§ 31, 32), are weak, this organ may be the first to suffer. 

282. The symptoms of asthenic plethora hitherto described, are chiefly 
those of a depressed or oppressed state of the functions. Sometimes, 
however, there arise others betokening excitement or reaction of an ir- 
regular kind. The pulse becomes quickened, and often irregular; the 
skin becomes hot, or partially perspiring ; sickness and vomiting may 
occur; the tongue becomes much furred, and sometimes brown and dry; 
the excretions are defective, unusually offensive, and often changed in 
appearance; the complexion becomes dusky, the eyes suffused, the men- 
tal faculties confused or impeded in low delirium or lethargy. This is a 
kind of congestive fever, described by Dr. Barlow 7 as a result of reaction 
from asthenic plethora. It is possible that this description has been partly 
drawn from cases in which, besides asthenic plethora, some morbid 
poison (§ 258) has been in operation; but many of the symptoms here 
named may be fairly traced to a congestive fullness of the blood-vessels, 
with an impaired action of the excreting organs (§§ 70, 171, &c); and 
consequently, with the diseased condition of the blood, w^hich we have 
described to arise from imperfect excretion (§ 248, et seq.). The mere 
stagnation or imperfect motion of the blood will prevent it from under- 
going properly the process of purification and elimination of its decaying 
materials, through the instrumentality of respiration and excretion: hence 
it becomes loaded with urea, lithic and lactic acids, and other effete ma- 
terials, which unfit it for its proper uses, and irritate and disorder the 
organs through which it passes. The process of reaction or febrile ex- 
citement, which occurs in cases of asthenic plethora, is sometimes more 
distinctly connected with the condition of the blood, as in the case of 
gout (§ 254), rheumatism (§ 251), and various cutaneous diseases, which 
become developed generally in the atonic or asthenic forms. 

[In thirty-one individuals suffering from well marked plethora, the 
mean of the fibrin was 2*7, which is rather below the healthy standard. 
Plethoric persons are consequently not more liable to inflammatory dis- 
eases than others, and an appeal to clinical experience will sustain this 
assertion. The organic materials of the serum do not offer any remarka- 
ble alteration in proportion or composition in plethora. The blood of 
plethoric persons is very highly colored. On coagulation* the serum will 
be found more or less deeply tinged; the clot is larger, of moderate con- 
sistence, and contains a good deal of serum, and is never buffed. If the 
blood has flowed very rapidly from the vein, there is sometimes a thin, 
transparent pellicle on the surface. 

In plethora, all the organic functions are more actively performed. 
There is a remarkable disposition to exaltation in the cerebral functions; 
the emotions are frequent and very mobile, without, however, those ex- 
aggerations and aberrations of sensibility, those nervous predominances, 
which almost constantly occur in anaemia. Plethoric persons are liable 
to certain accidents, as vertigo, dimness of vision, ringing in the ears, 
and heats in the head. These symptoms have been usually attributed to 



GENERAL PLETHORA. 



149 



cerebral congestion, a condition which has, however, never been ascer- 
tained. Andral thinks these phenomena sufficiently accounted for by 
the passage of an increased quantity of red corpuscles through the ves- 
sels of the brain. It is strange that, as we have seen, (§ 264,) opposite 
conditions of the red corpuscles as regards quantity, produce analogous 
phenomena. Plethora predisposes to hemorrhages. The bruit de soufflet 
never occurs in plethora, as has been erroneously stated. — C] 

283. Remedial Measures. — The means already described as useful in 
reducing an excess of red particles (§ 192) and fibrin (§ 214), are also 
applicable to the earlier and simpler states of plethora. In fact, in these 
states, the blood usually does exhibit this excess, for which blood-letting 
and other evacuants, and abstinence, are the chief remedies. The pro- 
priety of blood-letting in extreme degrees of plethora, is evinced by the 
extent to which it may be carried without causing faintness. Thus Dr. 
M. Hall found that, from patients with congestive apoplexy, from forty 
to fifty ounces might be drawn without producing syncope; whilst in 
acute inflammations, the tolerance is usually less by about ten ounces. 
The beneficial effects of blood-letting are sometimes immediately mani- 
fest, although they are somewhat contrasted in the two varieties of the 
diseases. In the sthenic kind, the pulse becomes softer, weaker and less 
frequent ; in the asthenic, it often improves in strength and regularity, and 
sometimes rises to a natural frequency. In simple and recent cases of 
both kinds, a sufficient blood-letting, with due avoidance of the causes of 
the plethora (so far as that can be accomplished), and the continued use 
of a little aperient medicine, may complete the cure. 

284. But if the plethora have lasted long enough to produce some of 
its ulterior effects (§ 282), blood-letting maybe an insufficient, nay, in some 
instances, it may be an unfit remedy. In both kinds of plethora, medi- 
cines which increase the excretions are generally indicated, and the diet 
must be much restricted ; but the particular mode in which these ends 
are to be accomplished, varies greatly in the two forms which I have 
been careful to distinguish. 

285. In sthenic plethora, not only the blood is in excess, but also the 
irritability and tone of the moving fibre. Here, then, besides removing 
the excess of blood, sedative and relaxing remedies (§§ 115, 122) are in- 
dicated. Antimonials, salines, digitalis, and hydrocyanic acid, and a 
cool regimen, w T e have found to answer this purpose; and these are often 
most useful in the treatment of sthenic plethora. The same remedies, 
with mercury, colchicum, and some others, fulfil also another indication, 
which may be present, to augment excretions defective from an over 
excited state of the capillary circulation, which borders on hemorrhage 
or inflammation. If any part should especially suffer, local blood-letting 
may be requisite to prevent such a result. 

286. In asthenic plethora of some duration, on the other hand, although 
blood-letting relieves them, it does not restore lost tone to the over-dis- 
tended vessels. Tonics (§ 124), and even stimulants (§ 119), may be 
necessary at the very time that blood is drawn ; and there may long be 
required such treatment as is calculated to restore the impaired functions 
of digestion and secretion, and to improve the depraved condition of the 



150 



PROXIMATE ELEMENTS OF DISEASE. 



blood (§ 174). In such cases, the continued use of alterative aperients 
and diuretics, such as mild mercurials, with rhubarb, aloes, or senna, 
salines, and taraxacum, nitric acid, iodide of potassium, &c, may pre- 
pare the way for various tonics, such as calumbo, bark and iron. In 
such cases, mineral waters, like those of Cheltenham, Leamington, and 
Llandrindod, are often of great service; first the saline, which are aperi- 
ent and diuretic, and afterwards the chalybeate, which, although tonic, 
usually contain enough saline matter to keep the secretions free. Some 
of the latter class, as the Bath waters, sometimes excite torpid and ple- 
thoric habits to a critical reaction, by bringing on a regular fit of gout 
(§ 254). 

The diet, which should be very spare in sthenic plethora, must not be 
too much reduced in that of the asthenic kind. The food should be 
simple, but nourishing, and adapted to the power of digestion. Stimu- 
lant drinks are not generally necessary; but previous habits must be 
considered, and not suddenly reversed. Regular out-door exercise, as 
much as the strength will bear without causing excitement or exhaustion, 
is a most salutary part of the regimen. 



SECTION IV. 

LOCAL HYPEREMIA. EXCESS OF BLOOD IN A PART. 
I. WITH MOTION DIMINISHED— CONGESTION. 

287. The true nature and distinctive characters of congestion, or local 
hyperemia with retarded motion, may be conveniently traced through its 
several causes, all of which agree in fulfilling the conditions here given 
as the definition of congestion, excess of blood in the vessels of a part, 
with diminished motion of that blood (§ 274). We have already found 
that parts of the vessels, and even the heart itself, become congested in 
asthenic plethora (§ 281) ; but this is as a part of a more general disease. 
"We have now to consider the causes and phenomena of congestion of 
blood in a part, which may occur independently of general disease. 

288. Blood-vessels become congested, or unduly distended with blood, 
when their proper elasticity and tone are overcome; and this may happen 
when an obstruction in the veins prevents the free escape of blood from 
them; or it may happen from weakness of the coats of the vessels them- 
selves, which yield to the pressure of the blood transmitted to them. 
The chief causes of congestion may be classed under these two heads: — 
1. Those of venous obstruction; and, 2. Those of atony of the vessels 
(capillaries and veins). Under these two heads, we shall notice various 
cases of congestion, which will explain and practically illustrate the sub- 
ject. In congestion from either of these causes, it is obvious that, as the 
blood accumulates in the part, its motion diminishes; for as the great 
source of its movement is the force from the heart directed through the 
arteries, if the arteries remain unenlarged, the force which the enlarged 



CONGESTION. 



151 



capillaries and veins receive, will be reduced by being divided in their 
greater area. 

289 (1). Congestion from venous obstruction. — When the arm is tied 
for venesection, the veins are compressed more than the arteries. Hence 
the veins swell, then the fingers become red, and, after a few minutes, 
purple, and the whole limb is swollen from the congestion of blood in 
its vessels. In like manner, cold applied to the surface of the body 
affects and contracts the veins more promptly than the arteries which lie 
deeper, and the capillaries speedily become congested, as evidenced by 
the purple color of the hands and face after exposure. Cold also im- 
pedes the circulation by increasing the adhesion of the fluid to the walls 
of the tubes, a mere physical operation, pointed out by Poisseuille. 
Congestions are caused in internal organs by an obstruction of the veins 
leading from them. Thus congestion of the brain may be produced by 
a tight cravat (§ 51), or by a tumor pressing on the jugular veins. 
Efforts of straining (§ 64), coughing, holding the breath, and asthmatic 
paroxysms, which impede the flow of blood through the lungs, cause 
congestions in various parts. Disease of the valves of the heart, w^hich 
prevents the blood from passing onwards through it, produces fullness of 
the veins and of the capillaries in both the pulmonic and systemic cir- 
culation. Tubercles in the lungs cause congestion of these organs. 
Obstruction to the transit of blood through the liver causes congestion in 
the abdomen, haemorrhoids, &c. The characteristic of congestion begin- 
ning with the veins is, that the veins as well as the capillaries are dis- 
tended : this appearance is obvious during life in cases of aneurism or 
other tumor compressing the veins of the neck; and after death in the 
full arborescent appearance of the veins in the congested part. Certain 
diseases of the organs of respiration, especially extensive emphysema 
of the lungs, in which the efforts of expiration predominate over those of 
inspiration, cause congestions, not merely by opposing the return of blood 
through the veins into the chest, but also by removing that suction influence 
which naturally much promotes the flow of blood in that direction at 
each inspiration. It has been pointed out by M. Berard (Arch. Gen, 
de Med., Jan. 1830), and by Mr. A. Shaw (Med. Gaz., July, 1842), 
that the circulation in the liver is, in health, much dependent on this in- 
fluence ; and it may be inferred that the diminution of this influence by 
extensive vesicular emphysema will assist in explaining why hepatic 
congestion is so commonly combined w T ith this pulmonary lesion. 

290 (2). Congestion from atony of the vessels. — This comprehends 
a numerous class of cases. In some, the atony of the vessels (§ 123) 
affects the whole system, as in case of extreme debility, adynamic fevers, 
and the sinking which precedes death. The heart then acts feebly, and 
without force sufficient to propel the blood through the whole circuit of 
vessels; these yield from want of tone, and most where they are least 
provided with tonic fibres; that is, in the capillaries and veins, especially 
of parenchymatous organs, which accordingly become congested. The 
blood gravitates chiefly in parts that are lowest in the position of the 
body; which, in their weak state, yield to the accumulating blood. This 



152 



PROXIMATE ELEMENTS OF DISEASE. 



occurrence of the congestion in undermost parts {hypostatic), is the dis- 
tinctive character of that of weakened vessels. Thus the posterior parts 
of the lungs, intestines, and integuments, are found much congested. 

291. In other cases, the weakness is local, without affecting the ves- 
sels generally, the weakening cause being applied to some vessels only. 
Over -distention is a common cause of congestive weakness of vessels. 
Thus from long continuance in one position, the lower vessels yield to 
the gravitating force (§ 51) of the blood, and become congested. This 
cause makes the feet swell after standing or walking long, especially in 
warm weather. A continued stooping posture, or lying with the head 
low, may occasion congestion of the brain, with headache, giddiness, 
confused vision, and may prove an exciting cause of apoplexy. Remain- 
ing long in a standing or sitting posture, often causes congestion in the 
hsemorrhoidal veins, liver, uterus, &c. Where the circulation is feeble, 
and the tone of the vessels weak (§ 123), these causes of congestion 
operate more readily and more permanently, than where the circulation 
is vigorous ; yet these congestive affections, the result of weakness, are 
often mistaken for inflammations. Many of the pains and ailments of 
delicate females, are of this nature ; and although temporarily relieved 
by depletory measures, are to be permanently counteracted only by 
tonic means (§ 124), which promote the vigor and equality of the circu- 
lation. 

It must be borne in mind, that congestion from mechanical causes, 
when it lasts long, may so weaken the vessels by over-distention, as to 
continue after their original cause has ceased to operate. Thus conges- 
tion of the brain or lungs, induced by a paroxysm of dyspnoea, or cough- 
ing, or by violent straining (§ 64), may not subside with the cessation 
of the effort; giddiness, headache, pain, dyspnoea, &c, remaining for 
some time. 

292. In considering the operation of cold as a cause of disease, we 
found that it chiefly operates by constricting the vessels of the surface 
and extremities, and thus throwing the blood inwardly, causing internal 
congestions by intropuhion (§ 77). If this exists long, the tone of the 
internal vessels will be impaired, and the congestions will not cease on 
the restoration of warmth to the surface. Thus a permanent congestion 
in the lungs, liver, kidneys, mucous or serous membranes, whichever 
happens to be predisposed, may result ; and this congestion may vari- 
ously disorder the function of the part, or may lay the foundation for 
inflammation. 

293. Malaria (§ 82), and the influences which produce continued and 
exanthematous fevers (§ 93), seem to have the same effect as external 
cold, but it is not so easy to explain how they operate. The cold stage 
of these diseases exhibits in a high degree, the marks of intropulsive 
congestion; and it is well known that in ague, the congestive enlarge- 
ments of the liver and spleen are among its most remarkable phenomena 
(§ 191). The congestion sremaining during the febrile stages of fevers, 
seem to be the chief causes of their inflammatory complications. 

294. Another cause of congestion is over-excitement of the vessels. 
It is well known that after a part has been inflamed, the vessels often re- 
main dilated, but without the signs of inflammation. This is well seen 



CONGESTION. 



153 



in the conjunctiva, the throat, the skin, and in certain ulcers, and might 
be exemplified in some internal organs. The liver and stomach show 
many signs of congestion after the excitement of stimulant drinks (§ 56). 
But we may, under the microscope, trace the production of congestion 
apart from inflammation. 

When a slight irritant, as a weak infusion of capsicum, is applied to 
the web of a frog, it first causes contraction of the vessels, especially the 
arteries (§ 120); then quickly follows enlargement of the arteries and 
other vessels with very rapid motion: after a while, the vessels gradually 
contract, and return to their natural size. But if the stimulant applica- 
tion be repeated several times, so as to prolong the determination of blood 
into the part, the vessels do not then uniformly contract. The arteries 
indeed shrink, but the capillaries and veins remain congested, and thus 
present completely the condition given in our definition, excess of blood 
with diminished motion (§ 287). This dilated state of the capillaries 
and veins must be chiefly ascribed to their losing tone after excitement 
(§ 123), more than the arteries; but the process which I have been de- 
scribing, is accompanied by changes also within the vessels; numerous 
pale corpuscles adhere to the sides of the small vessels, and contribute 
to impede the current, and cause congestion by obstruction. Whenever 
the stimulus applied has been strong, this obstruction amounts to entire 
stagnation, and many vessels appear much enlarged, and filled with 
stagnant blood, or rather with an accumulation of red particles entangled 
in the coherent pale globules. For this reason, the vessels in which the 
blood is stagnant, are of a deeper red than others, the red particles being 
arrested whilst the liquor sanguinis passes on. 

295. All that has been now described belongs to congestion, and there 
can be little doubt that the intense and deep redness sometimes seen in 
congested parts, is partly made up of vessels in which the blood is abso- 
lutely stagnant. W T e shall find that a similar congestion and stagnation 
exist also in inflammation, and may be the only change left by it to be 
found after death, where the inflammation has not existed long enough 
to produce its more characteristic results. It is for this reason impossible 
to discern by anatomical characters between recent inflammation and 
some forms of congestion. 

296. Congestion occurs in various organs and surfaces when their 
proper secretions are arrested, or suddenly diminished (§ 167). It is 
difficult to determine whether the congestion is the effect or the cause of 
the defective secretion in the first instance; and very probably the rela- 
tion is mutual: at least this is the most convenient view to take of the 
matter for practical purposes. Thus, means which increase the secretion 
(§ 172), will often remove the congestion; and those which relieve the 
congestion, generally restore the secretion. There is nothing inexpli- 
cable in this, even on the principles already laid down ; for the free flow 
of a secretion will help to unload and set free the distended blood-vessels ; 
and the means which free those vessels from their congested state, will 
restore that freedom of circulation through them, which best ministers to 
the secreting process. 

298. In the former edition of this work, I mentioned some cases of 
congestion which had not then been traced to any of the causes above 



154 



PROXIMATE ELEMENTS OF DISEASE. 



specified, although it was not improbable that further investigation would 
refer them to some of these causes. Thus when the blood does not un- 
dergo its proper changes in the lungs (§ 234), its passage through these 
organs is partially impeded, and it accumulates in the right side of the 
heart, and in the venous system generally. Congestions thus form a 
prominent part of the pathology of asphyxia. From the observations 
of Dr. John Reid, it appears that some obstruction also occurs to the 
passage of the blood through the systemic capillaries, as proved by the 
increased pressure in the arteries, indicated by the hsemadynamometer. 

I stated that it remained for future observers to determine wdiether 
these obstructions are connected with contraction of the vessels (§ 120), 
increased spissitude or cohesion of the blood, or other simply physical 
cause; or whether they depend on peculiar (vital) attractions and repul- 
sions exerted between the vessels and its blood, which properties are 
supposed by some physiologists to constitute an important element in the 
healthy, as in the morbid phenomena of the capillary circulation.* 

* Whatever influence the vita] properties of the blood may be supposed tp exert in im- 
peding the passage of the blood through the capillaries, I can see no reason for admitting 
that they in any degree contribute to its motion. That the power of the heart, distributed 
by the arteries, is sufficient to carry on the circulation, is apparent from several experiments, 
of which some performed by my colleague, Dr. Sharpey, are the most convincing. A sy- 
ringe, with a hsemadynamometer to show the amount of pressure used, was adapted to the 
thoracic portion of the aorta of a dog just killed, which vessel had been previously tied im- 
mediately above the renal arteries, and the vena cava inferior was opened at its exit from 
the diaphragm. Fresh bullock's blood, (deprived of its fibrin by whipping and straining, to 
prevent its coagulation,) was then injected with a pressure of three and a half inches of mer- 
cury, and passed out of the vein in a free stream, after having pervaded the double capillary system 
of the intestines and liver. When the pressure was increased to five inches mercury, the blood 
spirted from the vein in a full jet. When the aorta was not tied above the renal arteries, but 
left free, the same pressure was sufficient to drive the blood through the extensive ramifica- 
tions of the lower extremities. On the same instrument being adapted to the pulmonary 
artery, it was found that a pressure of from one and a half to two inches of mercury, was 
sufficient to propel the blood through the capillaries of the lungs, so as to flow freely from 
the left auricle or pulmonary veins. 

The amount of force thus used is not greater than that which the ha?madynamometer 
shows the heart commonly to exert in propelling the blood during life, in the systemic and 
pulmonary circulation respectively; and we thus obtain almost a demonstration, that the 
heart's power, distributed by the arteries, is sufficient for the process of the circulation. An 
intelligent reviewer of the former edition of this work, has opposed to this inference the 
case of a foetus without a heart, in which circulation and nutrition seem to have been well 
performed ; but before we can admit the force of such a questionable and exceptional fact, 
it must be proved that there was no compensatory muscular apparatus in the large vessels, 
such as is known to exist and aid the circulation in fishes and insects, to the structure of 
which these monstrosities often in other respects approximate. 

The chief arguments for and against the existence of vital properties of attraction and 
repulsion at sensible distances, have been well stated by Professor Allen Thomson, in the article 
" Circulation," in the Cyclopaedia of Anatomy, to which I would particularly refer the student. 
In addition to these, I would state that in many long and careful microscopic examinations of 
the circulation in the frog's web, variously modified by different agents, I have never witnessed 
any movement of the blood particles, which was not plainly referable to the action of the 
heart, or of vessels. The share which the arteries have in regulating the flow of blood, 
through the capillaries and veins, is most evident. When the arteries increase in size, the 
flow becomes very rapid and general; when they diminish, the flow is tardy, and even 
ceases in some capillaries; and when the arteries contract, so as to permit no blood to pass 
through them, the blood which still fills the capillaries and veins becomes quite stagnant, 
without a sign of spontaneous movement. When motion begins again, it may always be 
traced to an artery, which first admits a file of single globules, which come few and far be- 
tween, and in pulses; afterwards, as the artery enlarges, many rush in a continuous rapid 
stream, supplying proportionate motion to the vessels beyond. These observations pre- 



CONGESTION — CAUSES. 



155 



The researches of my friend, Mr. John Erichsen, (Edin. Med. and 
Surg. Joimi., No. 163,) on asphyxia, have satisfactorily settled this ques- 
tion in favor of the first of these alternatives, which was long since sug- 
gested by me (Med. Gaz., Sept. 1835 and 1838). After having shown 
that analogy is not opposed to the fact of the contraction of the minute 
arteries being excited by the passage of venous blood through them, Mr. 
Erichsen adds : — 

" But we may go a step farther, and prove that it (venous blood) ac- 
tually possesses this power; causing these vessels to contract distinctly, 
as I have several times observed, on examining under the microscope, 
the mesentery of rabbits, during and immediately after the process of 
asphyxia. This may be done without much difficulty, as the circulation 
of these animals, when quite young, continues for many minutes after 
the struggles of asphyxia have ceased. On asphyxiating a young rab- 
bit, a portion of whose mesentery had been conveniently fixed under a 
powerful microscope, the following phenomena will be observed to en- 
sue. For about a minute after the struggles of the animal have ceased, 
the circulation appears to be going on with its usual rapidity ; it then 
gradually becomes somewhat slower, the arteries contracting in size, 
containing less blood, and assuming a lighter and more tawny color than 
before ; whilst the veins become congested, and evidently fuller, assum- 
ing, when view T ed by transmitted light, a very beautiful crimson hue. — 
As the circulation becomes more languid, the arteries continue con- 
tracting, and acquire a lighter color, the diminution in their size, and the 
difference in the quantity of blood contained in them and in the veins, 
being most marked. The motion of the blood in the capillaries now be- 
comes oscillatory, the whole mass of blood being, at each impulse from 
the heart, slowly propelled forward, and then moving backwards. This 
to and fro motion continues for some time, and then ceases entirely. — 

cisely correspond with those since made by Mr. Erichsen. and numerous recent microscopic 
observers. In the recent work of Mr. Travers, on Inflammation, some terms are applied 
which might seem descriptive of spontaneous motion of the blood corpuscles, such as "pi- 
oneering corpuscles," but it is plain that this term is used figuratively, for Mr. Travers dis- 
tinctly traces the motion to the impulse of the heart, communicated to the adjoining capilla- 
ries. 

Many of the instances of supposed vital motions in the blood, and other organic mole- 
cules, are referable to mere physical causes. Similar movements may be seen, quite as ani- 
mated in appearance, on mixing, under the microscope, two drops of saline solutions of dif- 
ferent strength or nature; any insoluble powder in these drops moves, as it were, sponta- 
neously, and the motion continues until these drops have entirely pervaded each other. 
Still more lively motions are seen on adding any resinous tincture to water. Similar causes 
operate on blood molecules, giving them motions which appear to be spontaneous. But 
blood particles move also from another cause; they are not only carried by the current, but 
they are often changed in shape by it. Being vesicles, they swell or shrink by endosmose 
and exosmose, on any change in the density of the liquid in which they are conveyed ; and 
these changes affect their position and form, their aggregation and separation, in a manner 
which might readily give the idea of their possessing spontaneous motions. 

Although it seems unwarrantable to admit a self-motory power in the blood particles as 
aiding in the circulation, it is highly probable that changes in them, as well as in the vessels 
which convey them, may impede the circulation. The adhesion of the lymph globules to the 
sides of the vessels, and to each other, and, perhaps, the cohesion of the blood-discs, are 
changes likely to produce this effect. We shall find these have a large share in causing the 
obstruction of inflammation; and, as before mentioned, they probably operate in intense and 
long-continued congestion ; but Mr. Erichsen's observation disproves their operation in as- 
phyxia. 



156 



PROXIMATE ELEMENTS OF DISEASE. 



On restoring the heart's action by setting up artificial respiration, an im- 
pulse was evidently transmitted from the blood in the arteries to that in 
the capillaries, in a pulsatory and jerking manner, which was soon com- 
municated to the veins, driving forward the whole mass of globules ac- 
cumulated in them, and gradually becoming more equable and powerful 
until the circulation was completely restored. I have watched these phe- 
nomena most attentively in the mesenteries of young rabbits, and have 
never observed anything like spontaneous movements in the capillaries ; 
the blood contained in which was invariably most clearly and distinctly 
influenced, solely by the impulses it received from that contained in 
the arteries. Nor have I ever been able to discover any obstruction in 
the vessels, in consequence of the adhesion of colorless globules to the 
sides — a phenomenon that I especially watched for, and which has by 
several been supposed to occur. The diminution in the diameter of the 
smaller arteries, and the proportionate difference between them and the 
neighboring veins, were most evident, and were such as could leave no 
doubt, in my mind, as to the important part that the contraction of these 
vessels plays, in giving rise to an obstruction to the passage of the blood 
through them in asphyxia ; in which I have no doubt that it is the prin- 
cipal, if not the sole agent. 

These observations correspond perfectly with what I have many times 
observed in the frog's web ; and we may fairly infer that the same ob- 
struction which operates in the systemic circulation, will suffice also in 
the pulmonary. The notion of vital attractions of the blood for the ves- 
sels, or even of the aggregation of the red corpuscles (suggested by an 
imperfect observation of Mr. Wharton Jones), as causing the obstructed 
circulation of asphyxia, is not only superfluous, but untenable, for, were 
the obstruction in the capillaries and veins, the arteries, for a time at least, 
should exhibit distention, which the above description proves not to be 
the case. 

The instances of obstructed pulmonary circulation recorded in Mr. 
Blake's experiments, in which certain saline solutions (of salts of soda, 
silver, &c), injected into the veins, caused death, by obstructing the pas- 
sage of blood, without coagulating it or arresting the breath, will admit 
of the same explanation. 

299. We have considered atony of the small vessels (§ 290) as a chief 
cause of congestion : and it is so, not only by making them yield, and 
become distended by the accumulation of blood, but also by rendering 
them unfit to transmit the force of the current in its proper direction. 
Vessels which have lost their tone, become inelastic and tortuous, and 
the very accumulation of blood in them opposes an increasing obstacle 
to its passage through them. The physical principle to which I now re- 
fer is not generally understood, and I will illustrate it by some experi- 
ments. 

300. To one of Read's enema syringes, was adapted a tube with two 
arms; to one arm was fitted a brass tube two feet long, having several 
right angles in its course ; to the other arm was tied a portion of rabbit's 
intestine, four feet long, and of calibre (when distended with water) dou- 
ble that of the brass tube. The intestine was placed in curves and coils, 
avoiding angles and crossings, which might obliterate the canal. The 



CONGESTION CAUSES. 



157 



discharging end of both tubes was raised to the same height, that of the 
intestine being kept open by a short tube of metal. The tubes were then 
both filled by successive strokes of the piston ; and when they both began 
to discharge, the quantity received from each in a given number of 
strokes, was ascertained. Without giving the details, it may be stated 
that the small metal tube discharged from two to five times the quantity 
discharged by the larger but membranous tube ; the difference being 
greatest when the strokes of the piston were most forcible and sudden, 
by which the intestine, although much swelled at its syringe end at each 
stroke, conveyed comparatively little water. The difference was further 
increased by raising the discharging ends higher; and when both ends 
were raised to the height of eight or ten inches, the gut ceased to dis- 
charge, each stroke only moving the column of w 7 ater in it, but this sub- 
siding again without rising high enough to overflow. On increasing the 
force of the stroke, the part of the intestine nearest to the syringe, burst. 

The experiment was repeated in various ways, of which I will mention 
one, with a metal tube two feet eight inches long, and a bore three- 
eighths of an inch, and a portion of dog's intestine of the same length, 
but when distended, of double the diameter. The metal tube yielded 
three times more liquid than the intestine. 

301. These experiments show that flaccidity and increased length and 
size of the tube afford impediments to the passage of liquid through it ; 
and although the experiments exaggerate the difference between healthy 
and relaxed or congested vessels, yet they really prove that the increased 
tortuosity and number of vessels in a congested part, the greater mass 
of their contents, and the atonic flaccidity of their coats, do truly form 
additional obstacles to the passage of the blood through them, although 
the amount of these obstacles will vary according to the state of the con- 
nected circulation. 

These experiments illustrate a principle that is too little considered in 
animal and general physics; the loss or neutralization of force, by mis- 
direction. The blood-vessels, in their healthy condition, are so constituted 
as to make the most of the heart's propulsive power, and transfer it 
throughout their whole length ; but when dilated, tortuous, flaccid, and 
otherwise altered, they misdirect and exhaust it, (as in the experiment 
with the intestine:) it is partly expended in distending and dilating the 
nearer portion, whilst a sufficiency does not remain for the onward pro- 
pulsion of the blood, which therefore stagnates and accumulates in the 
congested vessels. We shall have other occasions to revert to this prin- 
ciple, which explains many anomalies of unequal circulation. It is pro- 
bably much concerned in keeping up the congestion which has been for 
some time established by other causes; and it maybe the means of 
perverting an increased flow through the arteries, which otherwise might 
sweep away the congested blood, — into that mixture of opposing forces, 
which exists in inflammation. This conversion of congestion into in- 
flammation frequently occurs in circumstances corresponding with this 
description. 



158 



PROXIMATE ELEMENTS OF DISEASE. 



THE SYMPTOMS AND EFFECTS OF CONGESTION. 

1. Effects in the congested part. 

303. When the arm is tied for venesection, the parts beyond the liga- 
ture become congested. At first the hand feels rather warmer than usual, 
and somewhat tender, from the distention of its vessels with warm blood, 
but it soon becomes numb, cold, and weak, showing that the want of 
circulation lowers its vital properties. In like manner, simple congestion 
generally impairs the vital properties of internal organs, although the 
undue distention of their textures by the increased mass of blood, may 
cause partial excitement. Natural contractility and sensibility are low- 
ered, whilst pain (§ 126), spasm (§ 114), and morbid sympathies (§ 149), 
are often produced, but in a manner much less distinct and constant than 
in inflammation or determination of blood. Thus congestion of the liver 
is sometimes accompanied by pain or tenderness; sometimes it is with- 
out either. Congestion of the stomach sometimes causes gastralgia, 
nausea, and vomiting, and altered appetite; but these symptoms are often 
absent when the amount of disease of the liver or heart, and the subse- 
quent occurrence of hsematemesis, leave no doubt that the stomach w T as 
congested. The same remark is applicable to the kidneys, the uterus, 
the brain, and other organs. We often see the tonsils and uvula congest- 
ed and enlarged, without pain or soreness. Impaired nervous and mus- 
cular function is a more constant concomitant than pain, or any symptom 
of irritation. 

304. The natural secretions of congested parts are sometimes at first 
augmented, as in congestion of the conjunctiva and Schneiderian mem 
brane from cold; but more generally they are diminished, as in bronchial 
congestion, (dry catarrh,) and congestion of the liver, kidneys, &c. But 
very commonly, congestion leads to an increased transudation from the 
whole distended capillaries, causing effusions of the w T atery and saline 
part of the blood, more or less impregnated with albumen, and some- 
times even with fibrin, as exemplified in the fluids of fluxes and dropsies. 

The process by which this is the effect of congestion or secretion, seems 
to be chiefly a physical one. The portions of the vascular apparatus 
most concerned in supplying the secreting structure, seem to be the mid- 
dle parts of the capillaries, which are often so turned or convoluted, as to 
receive the most direct force of the current from the arteries. But w T hen 
congested, the vessels leading to the middle capillaries become yielding, 
loose, and tortuous, and the force is much expended in dilating these be- 
fore it can reach the portions w T hich supply the secreting surface or cells ;* 
these portions are in the condition of the distant end of the intestine in 

* It may seem that this is taking too mechanical a view of the process of secretion; but 
be it remembered that I do not ascribe secretion wholly to mechanical agency, but only 
assert what is known to be a fact, that due force of the capillary circulation is a condition 
favorable to this process. In lately inspecting the beautifully injected preparations of Mr. 
Dalrymple, and Mr. Toynbee, I was particularly struck with the distribution of the capilla- 
ries of secreting surfaces, such as mucous and synovial membranes. These capillaries run 
pretty straight from the minute arteries, and end in loops and ampullae on the surface, the 
returning vessels passing back as straightly. The physical effect of this provision is obviously 
to direct the chief force on the terminal loops which supply the secreting surface. 



CONGESTION SYMPTOMS AND EFFECTS. 



159 



the experiment above related (§ 300), not duly receiving the force of the 
current. Thus the more essential effect of congestion is to impair the 
natural secretion. 

305. But the distention of the congested capillaries sometimes leads 
to a general exhalation of their more watery contents, which, mingling 
with the natural secretion, render it watery and sometimes albuminous. 
Thus congestion of the bronchi sometimes ends with bronchorrhcea. 
Congestion of the intestines causes diarrhoea; congestion of the uterus, 
leucorrhcea; congestion of the kidneys, watery and sometimes albumin- 
ous urine; congestion of the lungs and pleura, hydrothorax; of the heart, 
hydropericardium ; of the abdomen, ascites, &c. 

306. The element of congestion chiefly concerned in the production 
of these effusions, is extreme distention of the vessels. They are less 
commonly found, therefore, in mere hypostatic or gravitative congestions 
(§ 291), in which the distention is inconsiderable, but they more result 
from congestions from venous obstruction (§ 289), especially when these 
occur suddenly, whilst the vigor of the circulation is not impaired. 
Thus the congestions connected with diseased heart or liver, produced 
by acute attacks or other additional causes of obstruction, especially in 
plethoric subjects, if not soon removed, are pretty sure to end with drop- 
sy, flux, hemorrhage, or inflammation. The circumstances that deter- 
mine which of these results shall ensue, will be considered when we come 
to these proximate elements of disease; but it may be mentioned that 
besides distention of the vessels, the condition of the blood considerably 
influences the result; a watery state promoting the transudation (§ 222), 
whilst a highly albuminous and fibrinous blood (§ 195) requires more 
pressure to make its watery parts pass through the coats of the congested 
vessels. 

307. The same circumstances determine the character of the effused 
fluid. Where the blood is poor, the watery parts easily pass from con- 
gested vessels, even without much distention, and contain but little albu- 
men. But if the blood abounds in the protein compounds, more pressure 
is required before much effusion takes place: and then, when the pressure 
is great, the fluid effused often contains, not only albumen in large pro- 
portion, but self-coagulating fibrin also(§ 211.) Thus I have seen the 
fluid of the pleura and pericardium, in rapidly fatal obstructive mitral 
disease, coagulate spontaneously into a fibrinous crassamentum, when 
removed from the dead body. The gelatinous masses of lymph often 
found in the peritoneal sac of the abdomen and pelvis in ascites from 
contracted liver, I have no hesitation in referring to the same origin.* 

308. Fluxes arising from congestion of high tension exhibit an un- 
usual amount of animal matter of an albuminous or mucous kind, as in- 
stanced in bronchorrhcea, mucous diarrhoea, and leucorrhcea. I have been 
induced to suppose that the polypous concretions and pseudo-membran- 
ous films occasionally effused on mucous surfaces, may'result from long- 
continued congestion, with a highly fibrinous state of the blood (§ 195). 
I have seen these evacuated from the air-tubes, in one case, and in seve- 
ral others from the intestines, from time to time, for months, and even 

* This is the true pathology of the "fibrinous dropsies" of Vogel and other German 
writers. 



160 



PROXIMATE ELEMENTS OF DISEASE. 



years, without symptoms of inflammation, but under circumstances ren- 
dering it probable that congestion was present. Extensive disease of the 
heart existed in the former case, and disease of the liver or amenorrhcea 
in the latter. 

309. I have, for several years, referred albuminous urine (§ 249) to 
congestion of the kidney; -and this view has been lately confirmed by 
some experiments by Mr. G. Robinson. The following considerations 
led me to entertain this opinion: — 1. The urine often becomes albu- 
minous, during great embarrassment of the circulation in cases of organic 
disease of the heart or lungs (§ 289), when the kidneys are otherwise 
healthy. 2. I have, in many instances, observed temporary albuminuria 
during the cold stage of ague, and the congestive stage of eruptive 
fevers. 3. In granular degeneration of the kidney, the amount of albu- 
men in the urine is augmented by circumstances causing congestion of 
the kidney, and is reduced by remedies suited to remove this. 4. The 
most common form of Bright's disease of the kidney in its earliest stage, 
presents the appearance of a highly congested structure, and is excited 
by causes calculated to produce congestion, such as frequent irritation 
of the kidneys by stimulating liquors — congestion from exhausted tone 
(§ 294) ; continued exposure to cold, especially after the kidneys have 
been thus excited — congestion from intropulsion (§ 292): scarlatina pro- 
bably operates as the two last combined. 5. The albumen in the urine 
abounds most in the congestive (first) stage of Bright's disease — the ves- 
sels becoming more or less obstructed in the progress of the disease, by 
a deposit of fibrin with granular cells in the tubules, and in some in- 
stances around them, which deposit, at the same time, perpetuates some 
degree of congestion, whilst it supersedes the proper secreting structure.* 

310. From what has just been stated, it may be inferred that conges- 
tion, if continued, may affect the nutrition and structure of textures. It 
generally tends to cause an increased deposit in them, constituting a 
variety of hypertrophy, or overflow of plastic matter. Thus, with dis- 
eases of the heart which cause congestion, there is an increase in the 
weight of the viscera generally, more particularly of the lungs and liver. 
(Clendinning.) The enlargement of the liver and the spleen from long 

* The secreting structure is partly diminished in another way also. The granular deposit 
presses not only on the blood-vessels, but on the uriniferous tubuli also; and wherever it 
totally obstructs them, their office ceases. These tubuli becoming distended, form the serous 
cysts, so commonly found in granular kidneys, and sometimes in those which are not granular. 
But these cysts contain serum, or a gelatinous fluid, with little or no urine ; and this fact 
has been urged against the notion that they are dilated uriniferous tubes. The explanation, 
however, is not difficult. The secreting function of the kidney lies in nucleated cells lining 
the tubuli (Bowman) ; growing, filling, and bursting, as these cells do, by imbibition from 
adjoining vessels, this process, which is that of secretion, must be stopped when the cells are 
themselves pressed on by an accumulation of their own secretion, which cannot escape; but 
serous exhalation from the blood-vessels still goes on, displacing by endosmosis the urine, 
and at last distending the duct into a cyst. The same explanation will apply to the serous 
cysts of the liver. This view explains how retention of urine or bile, may lead to the sup- 
pression of the secreting power. 

The above note, which appeared in the first edition, represents the view which still 
appears to me the true one of the origin of cysts in the kidney, and it corresponds with the 
opinion advanced during the present year by Dr. George Johnson, in a paper read to the 
Medico-Chirurgical Society. At the same meeting, a communication from Mr. Simon repre- 
sented the cysts as enlarged epithelial cells, developed in consequence of the obliteration of 
many of the tubes. 



CONGESTION SYMPTOMS AND EFFECTS. 



161 



attacks of intermittent fever (called ague-cake), may probably be referred 
to the congestion which this disease is known to induce (§ 293). 1 have 
known a similar enlargement of these organs to ensue, after long con- 
tinued exposure to cold and damp (§§ 77, 292). 

311. But the hypertrophy resulting from congestion is probably not 
of a uniform kind, comprising equal growth of all the textures; but, 
arising from an effusion of lymph from the most congested vessels, it is 
an intervascular deposit — at' first mottling and exaggerating the appear- 
ance of the natural structure, as seen in the nutmeg liver and in the 
early soft stage of granular degeneration of the kidney — afterwards con- 
tracting and compressing the natural structure, and ultimately causing 
its condensation and atrophy, whilst the new deposit itself forms a 
granular or nodulated texture of low vitality (§ 211). 

312. Such I believe to be the nature and origin of some varieties of 
cirrhosis of the liver, and granular degeneration of the kidney. The 
variations which these structural diseases present, may often be traced 
to their degree of advancement, or to the extent to which they involve 
the structures : and an argument in favor of their origin in congestion, 
may be found in the fact, that they are commonly more advanced and 
extensive in the most dependent parts of the organs ; as the lower mar- 
gins of the liver, where congestion is most promoted (§ 290). It is 
highly probable, also, that these plastic products of congestion are, in 
some cases, more or less developed and further modified by determina- 
tion of blood or inflammation, and by the composition of the blood itself. 

Thus, in some instances, the deposit exhibits more of a fibrous or 
closely compacted granular character, firmly adherent to the investing 
membrane, which is more the character of an inflammatory product. In 
others, the deposit is loosely granular, or in irregular cells, often w T ith a 
predominance of fat globules, with little cohesion: indicative of a dege- 
nerative condition of the plasma, such as is found in scrofulous or ca- 
chectic states. 

Long-continued congestion in the lungs may cause hypertrophy of the 
intervesicular and interlobular texture, and in some cases, partial con- 
solidation of the vesicular structure itself. Such changes are frequently 
met with in connection w 7 ith long-standing disease of the heart, and 
abound most in the posterior parts of the lungs, and near their roots, the 
most vascular parts. In the membranes of the brain, and in the cap- 
sules of the heart, liver, and spleen, opaque thickening is often seen 
along the course of the blood-vessels, especially of the veins ; apparently 
the result of the overflow of nutritive matter from these vessels. 

2. Effects of local Congestion on the System. 

When a congestion is extensive, it has constitutional as well as local 
effects. In proportion as blood accumulates in excess in a part, it leaves 
the rest of the body with less than its proper share, and the limbs and 
surface generally may show various symptoms of weak circulation and 
want of blood. Thus with considerable congestion of the liver, lungs, 
or brain, the surface is pallid and chilly, the pulse w r eak and small, the 
extremities cold, there is a peculiar feeling of languor or weariness, 



162 



PROXIMATE ELEMENTS OF DISEASE. 



and all the functions are indifferently performed. Such an effect on the 
system may be produced artificially, by applying a tight bandage around 
both thighs at once, or even both arms in a weak person : the limbs beyond 
the ligature become congested ( § 289), leaving a deficiency of blood in the 
rest of the body. The extreme of this condition is the cold fit of an ague, 
in which extensive internal congestions are the most essential pathological 
change (§ 293). As in this example, so w T ith other extensive congestions, 
more especially if suddenly induced, as by cold (§ 294), a reaction may 
ensue (§ 16), causing quickened pulse and circulation, hot skin, and other 
phenomena of fever. Where this reaction is vigorous, it may fulfil its 
object in sweeping back the congested blood into the circulation, and 
thus restoring the balance. Where the reaction is weak, it will fail to 
remove the congestion, but constitutes a low r feverish excitement, often 
remittent in type, w r ith depraved functions, foul tongue, impaired excre- 
tions, restless nights, &c, which may proceed for an indefinite period, 
until a critical evacuation by sweat, urine, or diarrhoea (§ 171) terminates 
it, and with it sometimes the congestion that has induced it. In other 
cases, there is no symptom of reaction ; but the congestion, if extensive, 
is not without its injurious constitutional effects: the stagnant blood, un- 
purified and unrenovated, becomes gradually injured in its composition; 
and not only unfit for further use in the economy, but a source of con- 
tamination to the rest of the blood (§ 191), and a cause of cachexia in 
the system at large. Extreme results of this kind are presented in the 
slow operation of malaria in those continually exposed to their influence 
(§ 85), in the low apyrexial congestions which precede typhoid pneu- 
monia: but slighter and commoner examples are frequently observed in 
those whose general health suffers from continued congestion, and in 
whom the loaded and vitiated excretions which, even without fever, con- 
tinue to be thrown off, afford evidence of a process of decay in the ani- 
mal fluids, which is the necessary consequence of their imperfect purifi- 
cation. 



REMEDIES FOR CONGESTION. 

313. The most important means in the removal of congestion are those 
which contribute to the removal of their causes. Thus the loosening of 
a ligature, or the reduction of a tumor, compressing veins; the modera- 
ting, the inordinate and inefficient action of a diseased heart ; the re- 
storation of the secretion of the liver, (§ 172,) — will severally tend to 
diminish the congestions resulting from these different causes of venous 
obstruction. 

314. So, also, in the treatment of congestion from atony or weakness 
of the capillaries, it is important to remove the circumstances which have 
caused this atony. In many cases it is over-distention from gravitation 
(§ 296); here change of posture gives relief. Thus, in congestive fevers, 
and other states of continued weakness, it is useful to change from time 
to time the position of the patient from supine to prone, or lying on either 
side. With congestion of the head, this part should be supported high. 
The recumbent posture gives much relief to congested hemorrhoidal or 
uterine vessels; as we see it reduce the swelling of varicose limbs. 



CONGESTION — REMEDIES. 



163 



Pressure is sometimes a remedy for congestion, by supporting the weak 
vessels, and promoting their contraction. This forms a chief part of the 
useful operation of bandages, adhesive plasters, and even of poultices, 
in various external congestions. It probably might be more extensively 
applied to these, and even to some internal congestions, in the modes 
suggested by Dr. Arnott, by mercury, or by the soft slack air-cushion 
pad. 

Friction is a modification of pressure especially suitable to some forms 
of congestion, being calculated to give the motion that is defective, as 
well as to support the weak vessels. It is obviously useful in external 
congestions from cold; and sometimes in visceral congestions, as those 
of the liver and abdomen generally. Exercise operates somewhat in the 
same way. 

315. Another class of remedies for congestion comprehends those 
which promote the contraction of the dilated vessels by augmenting 
their contractility or tone (§ 124). In this way, astringents and cold 
operate ; as in the use of solutions of alum, sulphates of zinc or copper, 
acetates of zinc or lead, and infusion or decoction of oak bark, catechu, 
kino, nutgalls, &c, in various congestions, particularly of the conjunc- 
tiva, throat, rectum, and vagina. The most obvious part of the action 
of bark, quinine, and arsenic, in the cure of ague, is in their reducing 
the great visceral congestions, which form their most remarkable, and 
perhaps their most important, pathological element. 

316. The utility of astringents in congestion is limited by the fact, 
visible under the microscope, that they commonly contract the arteries 
more in proportion than the capillaries and veins, which are most dis- 
tended. Hence they may still further impair the motion of the blood, 
and increase the congestion. A reaction, however, sometimes occurs, 
wdiich converts the operation of the astringent into that of a stimulant, 
which is another kind of remedy for congestion. The same remark is 
applicable to cold : and even more so, inasmuch as it also causes a phy- 
sical obstruction* to the flow of blood, in the manner formerly described 
(§ 296). 

Stimulants sometimes are remarkably effectual in removing conges- 
tions. Thus diluted spirit lotion to a congested conjunctiva, capsicum 
gargle to a congested throat, a stimulating wash or ointment to a purple 
sore or surface, will often signally reduce the congestion. Other con- 
gestions are removed by exciting the circulation generally ; a stimulant 
draught, or even one of any hot liquid, relieves the pulmonary conges- 
tion w 7 hich has induced a fit of asthma; a congestive headache is some- 
times mitigated by similar means. Well-regulated exercise tends to dis- 
perse congestions in various parts. Various agents, which specifically 
excite particular organs or parts (§ 173), are often useful in removing 
congestions from them. Thus mercury is, in some cases, a remedy for 
a congested liver; some diuretics, as digitalis and cantharicles, for con- 
gested kidneys ; squill, benzoin, and other expectorants, for bronchial 
congestion. 

317. The influence of stimulants on congestion may be illustrated by 
the microscope. A solution of capsicum applied to a frog's web, con- 
gested after previous irritation, causes an enlargement of the arteries, 



164 



PROXIMATE ELEMENTS OF DISEASE. 



and an increased flow of blood to and through the congested vessels. 
This flow restores motion where it was deficient, sweeps away the accu- 
mulated blood, and, in some instances, causes the vessels to contract 
afterwards to their natural size ; so that the congestion is completely 
removed: in that case, the cure is complete. In other instances, how- 
ever, the stimulants fail to clear the congested vessels; the enlarged 
arteries pour in more blood ; but this, not overcoming the obstruction, 
increases the hyperemia, and, as we shall afterwards see, may convert 
it into inflammation. Thus it appears that stimulants, as well as astring- 
ents, although occasionally proving remedies for congestion, sometimes 
tend to increase it; and this they are most likely to do when the conges- 
tion is extensive, or of long continuance, or when its causes are still in 
operation. 

318. Under such circumstances, congestion is better relieved by 
another class of remedies, depletion, and various evacuants. Blood- 
letting, by puncture or incision in the congested parts, enables the dis- 
tended vessels to unload themselves, and they may recover their size ; 
and the utility of this expedient is shown in scarifications of congested 
conjunctiva and tonsils, and leeches to a congested os uteri. But the 
blood is more usually drawn from the vicinity of the congested part, 
as by cupping, or leeches on the chest or side for congested lungs or 
liver;* to the sacrum for congested uterus; or leeches to the anus for 
congested intestines. Or, without actually shedding the blood, it may 
be drawn away from the congested part by derivation; that is, by agents 
which cause determination of blood or congestion in other parts ; as dry 
cupping, mustard poultices, and other, stimulating applications to the 
surface, and by purgatives and other evacuants from the interior. A 
still more powerful agency of the class of derivants is that of removing 
atmospheric pressure from a limb by enclosing it in an air-tight vessel, 
and partially exhausting the air. This was invented by Dr. Arnott, and 
has been lately employed by Sir James Murray and several French prac- 
titioners. 

These act by inducing determination of blood, or even inflammation 
in another part, and thereby drawing away blood from the congested 
parts. Some means, however, may be employed, which prevent or re- 
move congestion by damming up the blood in other parts, and thus in- 
ducing a counter-congestion. It has long been practiced with success 
to stop a fit of ague by applying a tourniquet to the thigh; and Dr. 
Buckler of Baltimore, following a popular practice of a similar kind, 
has called the attention of the profession to the general utility of the 
remedial measures which he terms htemotase ; which consists in the 
temporary application of ligatures to one or more limbs, which are 
thereby so much congested, that there is not blood left in the circulation 
sufficient to supply the congested vessels, and these, relieved of pressure, 
may contract and expel the accumulated blood. I have employed this plan 

* It is remarkable how quickly congestions may be reduced by these means. I have 
known a congested liver, which reached from the umbilicus to the fourth right rib, (as traced 
by percussion,) reduced in twelve hours to its normal dimensions by cupping and free purg- 
ing. Piorry describes a still more speedy reduction of the liver in ague, by the influence of 
the sulphate of quinine. 



DETERMINATION OF BLOOD. 



165 



in several cases in which temporary congestions were produced in the 
lungs and liver, and sometimes with a very remarkable preventive effect ; 
but it has little influence on congestions which have long been formed, 
and acts chiefly on the distribution of blood in the larger blood-vessels. 

319. The operation of several of the foregoing agents, in combina- 
tion or succession, is generally more effectual than that of single ones 
in the cure of congestions. Thus congestion of the liver may resist the 
action of mercury, and may even be aggravated by it (§ 294), until the 
vascular distention has been partially reduced by local blood-letting or 
derivants; then the mercury, by increasing the secretion, reduces the 
remaining congestion. Congestion of the kidneys is augmented rather 
than diminished by diuretics, which then fail to increase the secretion of 
urine, but may only render it more albuminous (§ 304). But after some 
relief has been given by cupping to the loins, and hydragogue purgatives 
and diaphoretics, then some diuretics, particularly digitalis and cantha- 
rides, cause a freer flow of urine with less albumen. The same point 
might be further exemplified ; but it is unnecessary to multiply instances. 

320. The cause of congestion being, in many instances, atony of the 
vessels (§ 290), it may often be counteracted by circumstances which 
augment the tone of the vessels, locally or generally. Thus cold, as- 
tringent, or, occasionally, stimulant applications, by bracing the fibres 
and invigorating the circulation in a part (§ 124), render it less liable to 
congestion from disease ; and general tonic measures operate in a simi- 
lar way on the whole system. The efficacy of bark and arsenic in pre- 
venting, as well as in removing the internal congestions of ague, probably 
depends on their power of augmenting the tone of the vessels of these 
parts (§ 315), so that they no longer yield to the distensive accumulation 
of blood within them. A similar virtue seems to be possessed, in some 
degree, by iodine and its preparations, especially the iodide of potas- 
sium; under the use of which the disposition to local congestions is 
diminished, and those formed are sometimes dispersed, as exemplified 
by the external use of iodine in lepra and other congestions of the skin, 
and of iodide of potassium in congestive headache. Mineral acids and 
other tonics have a like effect in cases of general weakness. The treat- 
ment calculated to remove the results of congestion will be considered 
under the subjects, Hemorrhage, Flux, Dropsy, and Inflammation. 



SECTION V. 
local hyperemia.— excess of blood in a part. 

II. WITH MOTION INCREASED DETERMINATION OF BLOOD. 

321. Numerous examples of this kind of active hypersemia are pre- 
sented in health as well as in disease. The face and neck in blushing, 
the uterus and breasts at the periods of gestation and lactation, the gums 
during the process of dentition, the antlers of the stag at the season of 
their development, furnish instances of local determination of blood oc- 



166 



PROXIMATE ELEMENTS OF DISEASE. 



curring in health. The increased number and size of the blood-vessels, 
manifest by the vascular redness in these cases, show the increased 
quantity of blood in the part; and the stronger pulsation of the arteries 
leading to the part indicates the augmented motion of that blood (§ 274). 

322. In disease we meet with many examples. Determination to the 
head is one familiarly known ; and it affords the opportunity of display- 
ing one. of the characteristics of determination, in the enlargement and 
throbbing of the carotid arteries. I have witnessed this phenomenon in a 
great variety of cases. One patient was subject to attacks of determina- 
tion of blood, which caused him so much suffering and loss of moral 
control, that he cut his throat to destroy his life. When recovering from 
the wound, attacks sometimes came on ; first with beating of the carotids, 
then flushing of the face and head, suffusion of the eyes, and sensations of 
distraction in the head. In the slighter attacks, these symptoms would 
all pass away in a minute or two. I have, in several cases, observed the 
same symptoms usher in the paroxysms of mania. Fits of epilepsy and 
convulsive hysteria are immediately preceded by throbbing of the carotids, 
which shows that determination of blood is the proximate cause of the 
paroxysm. Drs. Darwin and Parry relate cases in which convulsive fits 
were prevented by pressure on one of the carotids ; and I have practised 
this expedient with success in several instances. Many of the epileptic 
patients whom I have questioned have stated that the fit is always pre- 
ceded by palpitation, which, for reasons before explained (§ 266), some- 
times peculiarly determines blood to the head. But without the patient 
being conscious of palpitation, there may be determination of blood to the 
head ; and in numerous observations, I have found this to be so commonly 
present, that I believe it to be the common immediate cause of the sudden 
paroxysms of various kinds of disorder which affect the nervous centres. 
Infantile and puerperal convulsions are probably to be included in this 
remark, although they may be connected with very different conditions 
of the vascular system in point of fullness, and are promoted by an im- 
perfectly purified condition of the blood itself (§ 249). 

324. But the most common cases of determination of blood are those 
caused by the application of stimuli. Thus heat causes a flow of blood 
to the surface ; snuff, to the nose and eyes ; spices in the mouth, to the 
salivary glands; food in the stomach, to its secernent vessels ; purgatives, 
to the vessels of the intestines, and those of glands connected with them ; 
diuretics, to those of the kidneys, &c. &c. In fact, in the operation of 
most medicines, there is an increased flow of blood to particular organs 
or surfaces; and there are few diseases unconnected with local determi- 
nation of blood. We shall find hereafter that it occurs in inflammation 
as a part of that complex process ; but Dr. Parry was wrong in supposing 
that inflammation consisted in this alone. 

325. Now, what is the physical cause of determination of blood ? In 
some cases, increased action of the heart (§ 112) may propel the blood 
with unusual force and quantity to the arteries in its immediate vicinity; 
more particularly when there is little blood in the system, and that little 
accumulates chiefly at and near the heart, as in cases of ana?mia (§ 266), 
or in the commencing reaction after great congestion of internal organs, 
as in the beginning of the hot stage of fevers: and thus determination 



DETERMINATION OF BLOOD. 



167 



of blood to the lungs and bronchi, the neck, and head, is a common re- 
sult of inordinate action of the heart. But in many of the examples 
above cited (§§ 323, 324), local determination takes place without any 
increase of the heart's action, and must therefore be due to another 
cause. 

Is such determination of blood caused by increased action of the ar- 
teries ? The only active property which we know these vessels to possess 
is that of slow or tonic contraction (§ 120) ; and such contraction of 
arteries leading to a part would diminish instead of increasing the mo- 
tion and quantity of blood proceeding to the part (§ 294). 

326. We may affirm, from direct observation as well as from reason- 
ing, that determination of blood is caused by enlargement of the arteries; 
and this enlargement is the effect of the pressure of the arterial distention 
from behind acting on a tube which has lost some of its contractile power 
(§ 120). The tonicity of the arteries makes them naturally resist the 
distending influence of the mass of blood pumped into them by the heart; 
but if the tonicity be impaired in any artery, that of other arteries forces 
into it the blood in augmented quantity, by which it is dilated, and 
becomes an enlarged channel for the transmission of more blood and 
more force (§ 323). If the artery be thus enlarged, the capillaries and 
veins leading from it will be also enlarged, and will share the increase 
of blood and motion thus supplied to them (§ 298, note). We find the 
proof of the enlargement and distention of arteries leading to an inflamed 
or irritated part in their increased and harder pulse; the coats of the 
vessels being stretched to tightness, the pulse is no longer softened by 
the usual elastic spring. 

So, too, in the frog's web gently irritated by an aromatic water we 
see the arteries become enlarged, supplying a larger and more impulsive 
flow of blood to the capillaries and veins, which all become enlarged 
also; and the whole vascular plexus, including vessels which before 
scarcely admitted red particles, then become the channels of a much in- 
creased current. This is determination of blood.* 

It has been objected that I assume enlargement of vessels to be the 
cause both of increased motion (in determination), and diminished motion 
(in congestion), which seems contradictory; but if the objector had duly 
considered my explanation, he w T ould have found no contradiction in 
it. In determination, the vessels enlarged are the arteries, which, being 
near to the source of motion, and highly charged with its propulsive 
power, give vent to the current as from a reservoir under high pres- 
sure ; whereas in atonic congestion the vessels enlarged are the veins 
and capillaries, which are remote from the source of motion, and receive 

* As these phenomena have not been distinctly described by observers apart from the 
further effects resulting from over-irritation, which leads to obstruction and inflammation, I 
will state shortly some results of many observations on the circulation of the frog's web, 
under the influence of moderate stimuli applied to it. These observations were made in 
the summer of 1841, and some of them are mentioned in my Gulstonian Lectures, pub- 
lished in the Medical Gazette of July, 1841. 

The arteries may be distinguished from the veins in the frog's web, not only by the 
direction of their current and its greater rapidity and transparency, but also by a series of 
lines along their course, marking the size to which they have been distended at some pre- 
vious time. (See A, Fig 1.) These lines or channelings are most distinct, and are more 
remote from the artery at its a,ngles or bifurcations. They are to be seen at some points 



168 



PROXIMATE ELEMENTS OF DISEASE. 



their impulse only through the arteries, which are not enlarged, or are 
even contracted (§ 294) ; and thus the accumulated blood becomes com- 
paratively stagnant. There is nothing contradictory in this simple ap- 
plication of hydraulic principles : and it is further illustrated by the fact, 
that those parts are most liable to determination of blood which are 
nearest to the source of power ; thus the arteries of the head, face, and 
neck, present this phenomenon much more frequently than those of the 
lower extremities. 

along the veins, but much less distinctly. Now these line are in themselves proofs of the 
varying distention of the arteries, and they also furnish the means of measuring this varying 
distention. 



Fig. 1. Fig. 2 




When a weak infusion of capsicum is applied by a camel's hair pencil to the web, there 
is a momentary retardation of the current in the veins, and the artery distinctly shrinks in 
size. But in a few seconds the reverse takes place; the artery swells to beyond its former 
size, and reaches the outmost line of its channel ; the flow of blood through it is too rapid 
to be distinguished, and all the capillaries present a scene of busy motion : in some the 
particles passing in numbers and speed greater than the eye can appreciate; in others, 
before invisible, single files force their way in more deliberate, but continuous motion ; 
whilst in the veins the movement is again more rapid. This motion soon begins to flag, and 
becomes remittent or oscillatory in some capillaries ; and it is seen that the arteries have 
already begun to shrink in size, and the channeled lines which they had reached re-appear. 
Sometimes, in shrinking, the artery assumes for a time a more tortuous shape than before, 
(as A, in Fig. 2;) so that its walls cease to be parallel with the lines, which seem to show 
that it contracts in diameter before its length is proportionally reduced. The contraction of 
the artery, and consequent reduction of the quantity and movement of the blood in the 
vascular plexus, was promoted by repeated applications of cold water (§ 124), which in some 
instances stopped the motion of the blood altogether, by contracting the artery to so small a 
size, that no blood particles entered it. A solution of acetate of lead also produced this effect. 

The determination of blood thus excited produces an increased redness quite visible to 
the naked eye, but it is less intense and of lighter hue than the redness of inflammation or 
congestion. 



DETERMINATION OF BLOOD. 



169 



3.27. There appears, then, to be no difficulty in tracing local determi- 
nation of blood to the physical cause, enlargement of the arteries leading 
to the affected part; and if it is not equally easy to give a physiological 
explanation of the cause of this enlargement, it is only because the laws 
of atonic contractility of arteries have not yet been sufficiently studied. 
The terms "active dilatation" (Hunter), and "vital turgescence" (Kal- 
tenbrunner), have been applied to the condition in question; but all that 
is known of animal physics is opposed to the possibility of there being a 
power of active dilatation in the arteries. 

The physiological cause seems to be a weakening or reduction of the 
tone (§ 123) of the artery; so that it becomes passively distended by the 
vis a tergo of the heart and arteries. In some cases, it might be supposed 
that this weakness is the result of exhaustion from stimulation (.'§ 116); 
and it has been stated above that a momentary contraction of the artery 
precedes its dilatation. But the dilatation is out of all proportion to the 
previous contraction ; and, in some cases, as in blushing, in the opera- 
tion of heat, and in the growth of parts, there is no sign of any previous 
contraction. 

328. Dr. Billing ingeniously conceives that, by stimulating the nerves, 
the nervous influence is drawn away from the vessels; and that their 
contractility, being derived from this influence, is thus impaired. But 
this view assumes that muscular irritability, even in its lowest form, 
tonicity, is a property derived from the nerves — an assumption unwar- 
ranted by the facts and opinions most generally received by physiolo- 
gists (§ 110). There can be little doubt that the nerves — especially the 
sympathetic (§ 152) — are sometimes concerned in causing determination 
of blood; and it is not improbable that their influence is that of reduc- 
ing the contractility of particular arteries, just as strong moral emotions, 
acting through the nerves, paralyze the sphincters and muscles of volun- 
tary motion (§§ 144, 154). So too, we have found that heat, which in 
moderate degree increases the irritability of muscles, impairs their toni- 
city, and cold has the reverse effect (§ 120). But the laws of tonicity, 
and its relation to the nervous influence, require further investigation. 

329. We can readily understand the final cause of determination of 
blood. "Ubi stimulus, ibi fluxus." The flow is intended to support the 
well-being and function of the part. If any influence disturb its well- 
being, or excite its function, more blood is wanted: the arteries dilate to 
supply more and in greater force, and thus the circulation through the 
part is augmented. The result is, in moderation, to increase the red- 
ness, warmth, sensibility, secretion, nutrition, and other functions of the 
part; in excess, to disorder and alter them. 

330. We have hitherto considered local determination of blood as re- 
sulting from causes which directly affect that part of the vascular system 
in which the determination takes place. In not a few cases, however, 
the same result arises from opposite causes acting on other parts of the 
vascular system. Thus as we found external cold cause internal con- 
gestions by intropulsion (§ 292), so too it may occasion internal determi- 
nations of blood. By constricting the vessels of the surface and extre- 
mities, it directs the force as well as the quantity of the circulating fluid 
on internal parts, or those beyond its influence. Thus, in many per- 



170 



PROXIMATE ELEMENTS OF DISEASE. 



sons cold to the surface and extremities, causes palpitation, dyspnoea, 
pain in the chest, throbbing, pain, and heat in the head, gastralgia, colic, 
and fluxes of various kinds. It is obvious that in such cases, the force 
of the heart is expended chiefly on the arteries of the internal organs, 
which thus become dilated, and the seat of determination of blood; whilst 
those of the surface and extremities are contracted and bloodless. The 
commencement of reaction from the cold stage of a fever is commonly 
marked by determination to the head and other parts near the centre of 
the circulation, which are thereby excited, and suffer more or less pain 
and disorder. 

The subjects in whom cold causes internal determinations of blood, 
are chiefly those endowed with much irritability of heart (§ 113), and 
with but little blood (§ 261). The same persons likewise are liable to a 
flush of blood to the face and head, w r ith coldness of the feet, when they 
go into a w r arm room. By cooling the head, the feet become warm ; or 
by warming the feet, the head cools. 

331. Attacks of local determination of blood, from other causes, are 
often accompanied by shivering fits, pallidity, coldness of the extremi- 
ties and defective secretions, particularly in persons of w T eak circulation. 
When an unusual quantity and force of blood is determined to one part, 
there must be less in other parts, which therefore suffer from the defi- 
cient supply. This furnishes an important therapeutic indication, to be 
noticed hereafter. 

332. As we find determination of blood to be chiefly produced by an 
enlargement of some arteries from a reduction of their tonicity (§ 326), 
so we may be led to expect that such enlargement may affect any part 
of the arterial system. We have chiefly considered it in relation to the 
distribution of blood to parts ; but it may also occur in the great arte- 
rial trunks. Inordinate pulsation of the aorta, especially in the abdomen 
at the cceliac axis, or at the bifurcation into the iliacs, (corresponding 
with a little below 7 the epigastrium and at the umbilicus,) is a common 
symptom in nervous subjects. Epigastric pulsation I have observed fre- 
quently before and after hsematemesis. In several cases nephralgia, ha> 
maturia, and lithic deposits in the urine occurred in patients affected 
with strong pulsation at the umbilicus. 

SYMPTOMS AND EFFECTS OF DETERMINATION OF BLOOD. 

333. Many of the symptoms of determination of blood maybe learned 
from the preceding illustrations. It generally causes a flush of heat, and 
exalts contractility (§ 112), sensibility (§ 126), and other nervous pro- 
perties (§ 149) of the part, exciting spasm, pain, irritation, and sympa- 
thetic disorder. In its moderate degrees, it increases the natural secre- 
tions of the part (§ 162), and thus becomes the cause of mucous, bilious, 
and urinary fluxes, &c. The nutritive function is a slow process and 
only affected by determination of blood when constant or often repeated ; 
then it is likewise increased, and more naturally than from congestion, 
the result being a more simple and general hypertrophy of the part. The 
process of absorption, although favored when the current is accelerated 



DETERMINATION OF BLOOD. 



171 



without distention, is often not equal to the effusion. Hence in sacs and 
cells determination of blood may cause dropsy. 

A few examples will suffice to illustrate the symptoms and effects of 
local determination of blood. 

334. The parts most subject to determination of blood are those nearest 
to the heart, and those most freely supplied with blood vessels (§ 30), as 
the brain, the parenchyma of glands, mucous membranes, and the skin. 

335. Determination of blood to the head often takes place in some per- 
sons from mental excitement, violent exertion, stimulant drinks, or de- 
fective excretion. The symptoms vary considerably; but increased 
beating of the carotid and temporal arteries, some flushing of the face 
and suffusion of the eyes, and an increase of the symptoms on stooping, 
or lying with the head low, are commonly present in all cases. The 
other symptoms are sometimes those of simple excitement of the nervous 
centres, painful throbbing in the head, excessive sensibility to light and 
sound, flashes in the eyes, noises in the ears, an excited state of the 
mind, rapid flow of ideas, sometimes bordering on delirium, wakefulness 
or dreamy sleep, restlessness and irritability of temper. Sometimes these 
symptoms are replaced by others indicating a temporary oppression of 
nervous functions, such as giddiness, drowsiness, stupor, imperfect vision 
and hearing, with apparent specks or mist in the eyes, impaired articu- 
lation and power of locomotion, occasionally with various convulsive 
affections, as in hysteria and epilepsy. 

336. It may seem difficult to explain how such opposite symptoms, 
those of excitement and those of oppression, are produced by the same 
cause — determination of blood. But the explanation is readily found on 
referring to the true nature of determination, and the different modes in 
which it affects the circulation within the head. Moderate excitement 
of the brain, as by bodily exercise, mental exertion, or certain beverages, 
such as tea or coffee, is accompanied by increased but equal flow of blood 
through the brain. But if these or other causes of excitement operate 
in excess, the arteries supplying the brain are still further dilated, and 
convey blood to it with more force without an equal increase in the pas- 
sage of the blood through it: and this for two reasons. 1. We have 
already found that a certain proportion in the size and elasticity of the 
vessels best qualifies them to transmit blood freely (§ 301); and that 
where this is wanting, increased force does not compensate for it, but 
often causes new disorder. Thus in violent palpitation of the heart, the 
aorta, carotid, and subclavian arteries are often dilated, and throb 
strongly; but the weak pulse at the wrists shows that much force is ex- 
pended on the larger trunks, without reaching their distant branches. 
This too is one reason why, in determination of blood to the head, the 
force is sometimes more expended in the larger vessels at the base of 
the brain than transmitted throughout its substance. 2. Another reason 
for unequal or defective excitement from determination of blood to the 
head, is the unyielding nature of the skull, which permits no considera- 
ble enlargement of any of the vessels within it, without a corresponding 
diminution of other vessels, and a general compression of the cerebral 
substance. Hence distention of the arteries beyond a certain degree, 
will compress and obstruct the small veins, and thus prevent that free- 



172 



PROXIMATE ELEMENTS OF DISEASE. 



dom of circulation on which functional activity depends. On these 
principles may be explained the production of symptoms of depressed 
as well as excited energy of the nervous centres, and often a mixture of 
both, from the same cause, determination of blood (§ 153). 

337. Determination of blood to the kidneys is caused by stimulating 
diuretic drinks, and besides the increased flow of urine, may produce 
pain in the loins and throbbing in the abdominal aorta; and the urine 
discharged may exhibit an increase not only of its water, but also of its 
acid matter, with more or less of the epithelial cells of the uriniferous 
tubes. Excitement of the circulation, by exercise or by nervous affec- 
tions, also reaches the kidneys; exercise carries off much fluid by the 
skin; but nervous excitement, where it fails to cause perspiration, deter- 
mines more to the kidneys, and this seems to be the source of the abun- 
dant flow of limpid urine which follows convulsive and other nervous 
affections. External cold operates in a similar manner, by constricting 
the superficial and extreme vessels ; it directs the blood in unusual 
quantity and force on internal organs, especially the kidneys ; hence 
enuresis. 

338. Determination of blood to mucous membranes is exemplified in 
certain forms of dyspepsia, in which sudden pain, or heat, or nausea, is 
felt in the stomach, accompanied by epigastric pulsation, and sometimes 
followed by eructation of sour or other liquid, and sometimes by hemate- 
mesis. These attacks are often induced by excitement, general or local, 
from irritant ingesta, and from external cold. In the intestines, a similar 
affection causes a diarrhoea: in the air tubes, bronchial flux; the common 
character of these affections being their sudden production under the in- 
fluence of various exciting agents. 

339. Determination of blood to the skin is often produced, not only by 
direct irritation, but from the influence of internal causes ; as in case of 
blushing from mental emotion, flushing of the face from acid in the 
stomach, and the general redness of the surface in reaction after cold, or 
at the commencement of fevers. In various chronic skin-diseases the 
effect of determination is seen in a brightening of the color of the erup- 
tion, which may take place in a few minutes. 

340. Determinations of blood are commonly transient, coming on 
suddenly and soon subsiding. When they are more permanent, they 
commonly lead to other disorders. In their immediate seat they cause 
either increased secretion, with the addition of more or less of the watery, 
saline, and albuminous parts of the blood or hemorrhage, or they may 
pass into inflammation. In other parts of the body, there is often, at 
first, coldness, and defective circulation and function (§ 330), but after- 
wards there may succeed a febrile reaction, with hot skin, accelerated 
pulse, scanty secretions, and other symptoms of inflammatory fever. 

341. The frequent recurrence of determination of blood, or its long 
continuance in a lower degree, affects the structure; increased nutrition, 
hypertrophy, being the result. This may be a natural kind of hyper- 
trophy, as in the case of muscles, which augment in size in proportion 
to their exercise, which increases the circulation of blood through them. 
So the uniform hypertrophy of the substance of the heart, and of other 
organs, after long-continued excitement of that organ, may be referred 



DETERMINATION OF BLOOD — REMEDIES. 



173 



to the increased determination of blood that has been kept up. In other 
cases parenchymata, as those of the kidneys and liver, exhibit alterations 
rather than mere growth; and albuminous deposits and granular degen- 
eration result. In these and other cases the effect on the structure is 
commonly modified by the occasional presence of congestion, inflamma- 
tion, and the plastic condition of the blood itself (§ 211). 

It is unnecessary to dwell further on the phenomena and results of 
determination of blood, as we shall have to advert to them in connection 
with its occasional results — flux and hemorrhage, and with inflammation, 
of which it is a component part. 

REMEDIES FOR DETERMINATION OF BLOOD. 

342. In the treatment of all cases of determination of blood, as of 
diseases in general, it is obviously proper, as much as possible, to remove 
the exciting causes. Thus in the numerous class of cases arising from 
the action of stimuli or irritants on the part which is the seat of the 
determination (§ 324), the removal of such irritants, or the diminution 
of their action by soothing or diluent remedies, is a first indication. 

343. If we are correct in tracing local determinations of blood chiefly 
to an atonic distention of the arteries supplying the part (§ 326), we may 
expect measures w T hich promote their contraction to be efficient remedies. 
This is the fact; for cold is one of the most effectual means which we 
possess for subduing determinations of blood ; and this w 7 as mentioned 
as a chief remedy for the element, defective tone (§ 124). Astringent 
agents are equally useful in some instances of local determination; as in 
the application of solutions of acetate of lead, sulphates of zinc and 
copper, nitrate of silver, and other astringent lotions to external surfaces 
(§ 326, note)\ but these are chiefly effective where the determination is 
quite local and unconnected with generally increased circulation, other- 
wise they become irritants rather than astringents (317). But besides 
cold and other astringents to the part w T hich is the seat of the determin- 
ation, and to the arteries leading to it, derivants, or means which draw 
aw T ay blood by relaxing other parts of the vascular system, are especially 
indicated by many preceding observations (§§ 330, 331, 340). Of these 
derivants, heat is the most effectual, especially when combined with 
moisture. 

344. Thus cold lotions or douche to the head, and the hot footbath, 
are among the best remedies for determination to the head. Taking copi- 
ous draughts of cold w r ater, or more sparingly of iced w 7 ater, will often 
relieve epigastric pulsation and palpitation of the heart. The warm bath, 
by deriving to the surface, will diminish the flow of blood to the kidneys. 
I have know T n severe nephralgia instantly relieved by cold affusion on 
the loins; but the practice is too hazardous to be recommended. 

345. Various evacuant remedies may also be employed to counteract 
determination of blood, by determining a flow in another direction; and 
thus purgatives, diuretics, and diaphoretics, are often useful. Of these, 
purgatives are by far the most powerful and sure in their operation, and 
are of great efficacy in determinations to the head. Change of posture, 



174 



PROXIMATE ELEMENTS OF DISEASE. 



by elevating the part which is the seat of determination, may sometimes 
be usefully practised. 

346. But the most powerful derivant is blood-letting, general or local. 
By the microscope it may be seen how opening a blood-vessel changes 
the currents of blood; the currents of many vessels are reversed and 
drawn towards the bleeding point, whilst in others they are retarded where 
they were before running with great speed. But blood-letting is unneces- 
sary and injurious in many cases of determination of blood, especially 
those attended with a deficiency of blood in the whole system; and, as 
we have seen, such cases are not rare (§ 330). Dry cupping is a good 
substitute in some instances ; but even this measure is more weakening 
than it is generally supposed to be, for much blood being extravasated 
into the skin and cellular texture, is really lost to the system as blood: 
its particles are changed, and their structure destroyed. 

The cases in which blood-letting should be used are those where 
determination to an important organ is combined with some general ple- 
thora or local congestion, or has continued so long as to threaten a ter- 
ra. - ■ ■ - * o 

mination in inflammation. A speedy blood-drawing, as by cupping or 
free venesection, will generally answer best. 

347. In the same class of cases, certain remedies are useful which 
seem to cause a general relaxation of the tonic fibres (§ 122) of the vas- 
cular system and an equalization of the force and blood which this sys- 
tem conveys (§ 331). Antimony is the chief of these; and it is most 
indicated where febrile reaction has begun. 

348. Another class of remedies suitable for determination of blood, 
attended with much excitement, are sedatives, or those which reduce 
the heart's action (§ 115), such as digitalis, hydrocyanic acid, and nitre. 
These are chiefly useful where the determination occurs in connection 
with palpitation, as in the case of the various convulsive or other sudden 
nervous attacks which I have proved to be so commonly excited by pal- 
pitation (§§ 322-3.) I have entirely cured several cases of convulsive 
hysteria, and much reduced the frequency of the fits in epilepsy, by 
these remedies, sometimes combined with cold affusion on the head in 
the morning, and the hot footbath at night (§ 331). Hydrocyanic acid 
probably operates chiefly on the organic excitomotory nerves, and by 
lowering their function prevents the undue excitement which they com- 
municate to the heart. In this respect it surpasses conium and hyoscya- 
mus, which are also sometimes useful in preventing determination of 
blood arising from nervous excitement. 

349. We have found (§ 330) that in many instances determination of 
blood to internal organs results from weakness of the circulation, and 
especially a want of tone in the whole vascular system (§ 123); so that 
under the operation of cold constricting the external vessels, or of irri- 
tations exciting internal organs, the latter monopolize most of the blood 
and force of the heart's action. In such cases, besides temporary means 
to equalize the circulation, (heat to the extremities and surface, cold and 
astringents to internal organs, gentle exercise, friction, &c.,) more per- 
manent remedies are to be sought in tonics, and various particulars in 
diet and regimen, which give strength to the contractile fibre (§ 124), 
and improve the quantity and quality of the blood (§ 271). 



RESULTS OF HYPEREMIA HEMORRHAGE. 



175 



Thus preparations of iron and bark are useful remedies in cases of the 
weaker kind; mineral acids, iodide of potassium, mild bitters, and the 
slighter metallic tonics, nitrate of silver, sulphates of zinc and copper, 
are serviceable in others which will not bear the stronger tonics. In the 
use of any of these remedies it is necessary to guard against their ex- 
citing effects on the parts which are the seats of determination, by pre- 
mising or conjoining the temporary remedies (§ 342, &c.) against that 
condition, and by keeping the secretions free and equally balanced. 

In all cases, country air, and exercise suited to the strength of the 
patient, and habits of posture opposed to the peculiar determination, 
will be found useful in removing and preventing this morbid affection. 

* 



SECTION VI. 

RESULTS OF HYPEREMIA. 

350. Before we proceed to the third and more complex variety of local 
hyperemia, inflammation, we must notice some remarkable results to 
which the other varieties, when increased to a certain degree, tend, when 
yet short of the conditions necessary to constitute inflammation — I mean, 
hemorrhage, flux, and dropsy. These results have been already men- 
tioned as sometimes ensuing from plethora, congestion, and determination 
of blood, and in describing hemorrhage, dropsy, and flux, it will be un- 
necessary to do more than exemplify their occurrence in connection with 
these proximate elements, and to trace the further peculiarities which 
distinguish each of these results. 



I. HEMORRHAGE. 

351. When, in any form of hyperaemia, the blood-vessels are distended 
to a great degree, they sometimes give way, and blood is effused. I 
shall give illustrations of the more common cases of hemorrhage proceed- 
ing from the several kinds of hyperemia which have been already de- 
scribed. 

General plethora (§ 275) not unfrequently causes hemorrhage from the 
nose (epistaxis), from the stomach (hcsmatemesis, vomiting of blood), from 
the rectum (hcemorrhois), and into or upon the brain [apoplexy). The 
operation of each of these, except the last, is more commonly favorable 
than otherwise, in reducing the excessive fullness of the blood-vessels; 
but they may be attended with unpleasant symptoms, and require con- 
trol. 

352. Congestion from venous obstruction (§ 289) produces hemorrhage 
in the cases of pulmonary apoplexy (hemorrhage into the parenchyma of 
the lungs), from obstructive disease of the left side of the heart ; bron- 
chial hemorrhage and hcemoptysis (spitting of blood) from tubercles in 
the lungs; hcsmatemesis and bleeding piles from obstructions of the liver 
from disease or violent straining. 



176 



PROXIMATE ELEMENTS OF DISEASE. 



353. Congestion from weakness of the vessels (§ 290) often causes 
hemorrhage in various dependent parts, in congestive fevers, and in 
various passive hemorrhages of weak subjects. A stooping posture has 
been known to cause cerebral hemorrhage (apoplexy). The erect pos- 
ture may bring on uterine hemorrhage (§ 291). 

354. The congestion of the head from the intropulsive operation of 
cold (§ 292), sometimes leads to epistaxis and apoplexy; that from pre- 
vious excitement of the stomach and kidneys in drunkards (§ 294), 
occasionally causes hasmatemesis and hcematuria (bloody urine). The 
congestion of the kidneys in scarlatina, and in the cold stage of ague, 
is sometimes followed by haematuria. 

#355. Hemorrhage, from determination of blood (§ 322), is exemplified 
in cases of epistaxis and apoplexy, preceded by increased beating of 
the carotids, flushing of the face, &c. (§ 335); ha?matemesis from va- 
rious irritants in the stomach (§ 338); hematuria from stimulant diure- 
tics (§ 337); bloody dysentery from drastic purgatives, &c. [§ 324). So 
also we shall find hemorrhage to be a common concomitant or result of 
inflammation. 

356. But all cases of general or local hypersemia now noticed, do not 
result in hemorrhage; some additional element is wanting; and this ad- 
ditional element may be either in the blood-vessels or in the blood. 

357. The blood-vessels are sometimes obviously in a diseased state. 
Inelastic andfragile from osseous or atheromatous deposit, or aneurismal di- 
latation, the arteries of the brain become ruptured under the influence of 
congestion or determination of blood. Softened and lacerable from inflam- 
mation or malnutrition, blood-vessels give way in various structures ; and 
in this way, hemorrhage occurs from an inflamed stomach or colon, in 
tuberculated lungs, in a softened brain, and in a diseased uterus. Some- 
times, actual ulceration or suppuration opens an artery or vein, and this 
is not a very uncommon cause of hemorrhage in chronic ulceration, in 
suppuration of lymphatic glands or tonsils, and in malignant disease of 
the stomach, intestines and uterus. Mechanical injury may rupture 
blood-vessels in the kidneys and nostrils; hence the haematuria and epis- 
taxis which sometimes follow violent blows in the loins, or on the nose. 
I have, repeatedly known haematemesis to ensue from the act of lifting a 
heavy object from a height, which, with peculiar force, compresses the 
liver. 

358. In other instances, the hemorrhagic disposition can be traced to 
a peculiar state of the blood, which is defective in fibrin (§ 196), but 
abounding in red particles (§ 184), as in petechial fevers, congestive 
apoplexy, hemorrhagic small-pox and other exanthemata. But there are 
other cases, in which the disposition to hemorrhage prevails without any 
defect of fibrin, or excess of red particles ; scurvy and purpura are ex- 
amples. In the former, there is found to be the very reverse of these 
changes (§§ 185, 196).* It appears probable that an alteration in the 
quality of the red particles (§ 186) and fibrin (§ 203), is the real evil in 
these diseases. The readiness with which textures become stained with 

* In acute hemorrhagic purpura, the fibrin is not deficient, for I have found the blood 
effused under the skin firmly coagulated. I have before mentioned my experience that pur- 
pura is generally connected with imperfect action of the liver (§ 171). 



RESULTS OF HYPEREMIA — HEMORRHAGE. 



177 



the coloring matter, the purple, brownish or party-colored stains left by- 
inflammation, and, in extreme cases, the altered appearance of the blood 
itself, seem to show the coloring matter to be diseased ; the failure of the 
healing process, and the remarkably loose and blood-stained appearance 
of fibrinous coagula which form on the spongy gums, or in wounds, seem 
to indicate a want of contractility and vital plasticity in the fibrin (§ 211). 
Further microscopic observations are wanted on these subjects ; some 
have already been noticed (§§ 203, 187). 

359. Another question connected with hemorrhages relates to the 
mode in which the blood is effused. We have just seen that, in some 
cases, blood-vessels are distinctly ruptured (§ 357). But in other instances, 
blood has been poured out in considerable quantities from various mucous 
surfaces, and even from the skin, without any discernible breach of 
vessels, or even of the surface. This statement has been made, parti- 
cularly in regard to epistaxis, haematemesis, and some remarkable cases 
of hemorrhage from the skin, occurring successively at different parts of 
the body. Considering the size of the red particles of the blood, and 
the absence of any visible pores in the walls of the blood-vessels, even 
under the highest magnifying powers, it does not appear possible that 
the particles can escape from the vessels without rupture either of the 
particles or of the vessels. At the same time, it may be stated that in 
the frog the red particles do pass through capillaries of calibre smaller 
than their short diameter: and in so passing, I have often seen them 
rolled up in the manner of an ice wafer. J. Hewson noticed the flexible 
and extensible property of the red corpuscles, and it has been confirmed 
by his commentator, Mr. Gulliver. The appearances of capillary apo- 
plexy (cerebral hemorrhage), and hemorrhagic inflammations of serous 
membranes, countenance the opinion that many minute vessels become 
ruptured at once, probably in connection with an altered condition of the 
blood: and such minute ruptures occurring in membranes, would not be 
discernible by common modes of examination. All cases of this descrip- 
tion which have lately come under my notice, have included the element 
already noticed, an altered state of the blood (§ 358), generally of the 
nature of uraemia (§§ 171, 249) or cholsemia (§ 250). 

VARIETIES OF HEMORRHAGE. 

360. Besides differences in seat, hemorrhages are distinguished into 
active or sthenic, and passive or asthenic; and the peculiarities of these 
varieties may be traced to the same elements as the corresponding 
varieties of general and local hyperemia (§ 279), excess and defect of 
the contractile power of the heart (§ 110), and of the tonicity of the ar- 
teries (§ 120). Thus hemorrhages, preceded or accompanied by the 
symptoms of sthenic plethora (§ 280), or with determination of blood 
(§ 322), are active or sthenic; whilst those occurring in connection with 
asthenic plethora (§ 281), or with mere congestion (§ 287), are passive 
or asthenic. We may, therefore, refer to the symptoms described under 
these subjects for the precursory symptoms of each kind of hemorrhage. 

361. But when the hemorrhage begins, it may modify the previous 
symptoms in various ways, besides the new local signs which the dis- 

12 



178 



PROXIMATE ELEMENTS OF DISEASE. 



charge of blood produces. In active hemorrhage, the full, hard pulse of 
sthenic plethora becomes modified by a remarkable jerk or thrill, which 
is an important symptom where hemorrhage is only suspected. I have 
noticed this thrill in the pulse even when the loss of blood has been 
very trifling, and where no murmur accompanies the heart sounds; and 
I am therefore inclined to think that it depends on an unusual abruptness 
of the heart's contraction (§ 113), combined with irregularities in the 
tonicity of arteries in different parts (§§ 326, 332); which cause these 
to react in successive jerks at each pulse, instead of simultaneously. 
In fact, this same thrill sometimes is felt during a paroxysm of determi- 
nation of blood to a part without any hemorrhage resulting. 

361. If the quantity of blood effused be large, and especially if its 
loss be rapid, syncope, or various degrees of faintness and weakness, 
may ensue. The pulse becomes small, weak, and often irregular, the 
surface and lips pale; either consciousness, or the heart's action, may 
first fail, according to the posture of the patient (§ 70), and the condition 
of ansemia (§ 262) is induced. 

362. Even after this faint state has been induced, in the course of a 
few hours the increased action (reaction) returns; and it is under the in- 
fluence of this that the pulse exhibits the greatest degree of the jarring 
or vibratory character; so that it may feel like a loose wire twanging, or 
a rough file drawn under the finger. With this state of the pulse, pal- 
pitation, throbbing of the great arteries, and the various symptoms of 
partial nervous excitement described under the head of ansemia, some- 
times occur (§ 265). During this reaction, the hemorrhage may be 
renewed. 

363. If the hemorrhage is inconsiderable, or if it be suddenly checked 
by styptics before the vascular fullness or determination has been re- 
duced, inflammation may ensue, with increasing strength and hardness 
of the pulse, heat of skin, and other symptoms of inflammatory fever. 
On the other hand, hemorrhage to a considerable extent may remove the 
hyperemia, and the various local and general symptoms of oppression, 
fullness, tightness, pain, and functional derangement which it had pro- 
duced. Thus w T e find headache and flushing often relieved by epistaxis ; 
pain and oppression in the chest by haemoptysis; abdominal pain and 
pulsation by haematemesis, melaena, or hemorrhoidal flux. 

364. But the blood effused may produce various disturbances and symp- 
toms in the parts into which it is effused. Within the head it presses on 
the brain ; and by interrupting the circulation through it, it may cause 
coma or paralysis (§ 273); or it may also break up the substance of the 
brain, and cause death by syncope (§ 116) and asphyxia combined. In the 
lungs, the blood may at once suffocate by its quantity, or cause dyspnoea 
and cough until it is expectorated. Here, too, it sometimes breaks up 
the texture of the lungs, leading to serious disorganization. In glands 
it forms swellings, or is mixed with, and modifies, their secretions, as in 
the case of hsematuria. In other complex textures, it produces swelling, 
often followed by local inflammation ; as instanced in the cutaneous swell- 
ings of purpura hemorrhagica. 

365. Passive or asthenic hemorrhage may be preceded by symptoms 
of asthenic plethora (§ 281) or congestion — may be accompanied by symp- 



HEMORRHAGE — TREATMENT. 



179 



toms of exhaustion if the loss is profuse, of relief if it be moderate ; and 
anaemia may ensue from excessive loss; or reaction, sthenic hemorrhage, 
or inflammation, if the hemorrhage is too suddenly checked. The he- 
morrhage connected with an altered state of the blood, is generally of the 
passive kind, although excitement, or determination of blood (molimen 
hcemorrhagicum) , sometimes comes on here also. 

TREATMENT OF HEMORRHAGE. 

366. As hemorrhage is commonly a result of plethora, congestion, or 
determination of blood, the remedies for these morbid elements will be 
more or less needed in its treatment. But the necessity for using these 
remedies will much depend on the extent and seat of the hemorrhage, 
and the mischief likely to result from its continuance. For example: a 
moderate epistaxis or hemorrhoidal flux needs no treatment; it is a natu- 
ral cure for a previously existing hypersemia. But if these hemorrhages 
be profuse, whether of the sthenic or asthenic kind, they must be restrain- 
ed: if sthenic, by artificial bleeding, which is under control, and by de- 
rivants to other parts, to reduce the fullness which causes the hemorrhage : 
if asthenic, by styptics, combined with derivants, to save the blood, the 
loss of which is injuring the system. 

367. But in some cases, hemorrhage to any amount may be injurious, 
and should be opposed from the first, both by remedies for the hypersemia, 
which is the cause of the hemorrhage (§ 345, et seq.), and by styptics, 
which peculiarly counteract this result. Thus hemorrhage from the lungs, 
or into the brain or other organ, requires prompt interference. The same 
rule may be applied to cases of excessive hemorrhage of any kind in all 
cases, and of more moderate hemorrhage in very weak subjects; in all 
of which the loss of blood is a pressing danger. 

368. In active hemorrhage, generally, blood-letting may be used until 
the hemorrhage is arrested, or the pulse reduced; and this effect should 
be sustained by other evacuants, especially purgatives and diuretics. 
Remedies which diminish the power of the heart, such as digitalis, hy- 
drocyanic acid, and nitre, and those which also reduce the tonicity of the 
arteries, especially antimonial medicines, are likewise of great use in some 
active hemorrhages. Another powerful agent in hemorrhage, connected 
with increased action or determination of blood, is cold(§ 343). Thus 
ice, or a stream of cold water on the nose and forehead in case of epis- 
taxis, ice swallowed in hsematemesis, ice applied externally, or icy water 
injected, for uterine hemorrhage, is of considerable efficacy (§ 344). I 
do not approve of the practice recommended by some, of applying ice to 
the chest for haemoptysis; I have seen pneumonia thus induced. Cold 
water is sometimes very effectual in arresting the flow of blood from a 
wound, and Dr. 0. Rees has suggested that, in addition to its constringent 
operation on the vessels, it may arrest the capillary circulation by causing 
the red particles to swell up by endosmosis. 

The treatment of passive or asthenic hemorrhage, besides styptics to 
prevent excessive loss of blood, will include remedies for general ple- 
thora (§ 286), or local congestion (§ 313, &c.,) which may cause the 



180 



PROXIMATE ELEMENTS OF DISEASE. 



hemorrhage. Hence, general or local depletion, derivants, accompanied 
or followed by tonics, may be useful. 

369. We have now to consider the means calculated to restrain all 
kinds of hemorrhage, and which are especially opposed to the causes 
which more immediately determine this result of disordered circulation 
(§ 356). If blood-vessels are softened, brittle, or actually ruptured or 
ulcerated (§ 357), a chief thing to be done is to diminish the quantity 
of blood sent to them • and, besides by blood-letting, this may be effected 
by pressure, posture, cold and astringent applications, and means calcu- 
lated to tranquilize the whole circulation. Thus epistaxis is sometimes 
arrested by pressure on the carotids; uterine hemorrhage, by pressure on 
the abdominal aorta, or by elevating the pelvis ; haemoptysis, by keeping 
the chest high : and in all cases of hemorrhage, perfect stillness and a 
cool regimen should be observed. 

370. The other pathological condition which favors hemorrhage, the 
altered state of the blood (§ 358), is, perhaps, more directly influenced by 
the remedies called styptics. Most of these remedies are astringents, 
causing contraction of the tonic fibres of vessels and other parts, but 
some of them also coagulate the blood, and in both these ways, they may 
tend to restrain hemorrhage. 

Of those which cause both contraction of the vessels and coagulation 
of the blood, the most powerful are acetate of lead, alum, sulphate of 
copper, chloride of zinc, nitric and sulphuric acids. Other styptics, as 
nitrate of silver, sulphate of zinc, sulphate of iron, and infusion of nut- 
galls, are certainly astringent, and are generally supposed to coagulate 
the blood; but Mr. Blake's experiments show that they have not this 
latter effect, when injected into the veins of living animals; (see note to 
§ 214.) It is, however, possible that, in a concentrated form, as where 
applied topically, they may coagulate the blood in the bleeding vessels. 
This seems to be the effect of nitrate of silver when applied to leech- 
bites. The actual cautery operates in a similar w T ay. 

In some cases of hemorrhage, the styptic remedies may be applied 
directly to the bleeding part, as in epistaxis, haematemesis, hemorrhoids, 
and uterine hemorrhage. In epistaxis, solutions of alum, acetate of 
lead, and sulphate of zinc, are sometimes injected into the nostrils, or 
applied by sponge or lint. In haematemesis, sugar of lead, alum, gallic 
acid, oil of turpentine in small doses, and the mineral acids, given by 
the mouth, operate directly on the bleeding part. In excessive hemor- 
rhoidal flux, enemata, containing some of these remedies, are immediately 
beneficial. 

371. In many instances, the bleeding part is beyond the reach of the 
direct application of styptic remedies; yet some of these, administered 
internally, show considerable power in restraining the hemorrhage. 
Thus, haemoptysis is assuredly sometimes checked by frequently repeated 
doses of sugar of lead, (which should be combined with a little opium or 
conium, to prevent its griping the bowels;) and, according to some prac- 
titioners, by ipecacuanha, gallic acid, alum, and other astringents. 
Hematuria of the passive kind is diminished by small doses of oil of 
turpentine; passive uterine hemorrhage, by gallic acid, ergot of rye, and 
tincture of the sesquichloride of iron. Opium given internally, has been 



FLUX AND DROPSY. 



181 



found effectual in some cases of uterine hemorrhage. It is difficult to 
explain how it operates; but it is probably through that property by 
which it diminishes many secretions. 

372. In some kinds of hemorrhage, especially those of the intestinal 
canal, the most effectual remedies are those which increase the proper 
secretions of this canal, and of its allied glands; such as mercurial and 
saline purgatives, in combination with others of a styptic kind, such as 
sulphuric and nitric acids, alum, and sulphate of zinc. This mode of 
treatment is often sufficient in slight hemorrhages, or dispositions to 
hemorrhage, from the lungs and uterus, and in purpura hsemorrhagica ; 
and there can be little doubt that it operates on the condition of the 
blood, as well as by its evacuant and styptic effects. 



II. FLUX AND DROPSY. 

373. Another result of various kinds of hyperemia, is an effusion of 
the watery part of the blood, with more or less animal and saline matter 
in solution. This result, occurring in secreting organs or open surfaces, 
constitutes fluxes ; in closed sacs or cellular texture, it constitutes dropsies. 
There is so much that is in common in the pathology of fluxes and 
dropsies, that we shall avoid repetition by exemplifying them together 
in the first place ; and we can afterwards notice their distinguishing 
peculiarities. 

374. General plethora sometimes ends in flux or dropsy ; but such a 
result most commonly ensues where the blood-vessels are temporarily 
distended with an undue proportion of watery contents. Thus, if much 
water be slowly injected into the veins of an animal, the circulation and 
breathing become embarrassed; and after a time, dropsical effusions take 
place into the abdomen, the chest, and the cellular texture; or a flux 
(excessive flow) takes place from the kidneys, intestines, or skin ; or all 
these results may occur ; and the blood-vessels are relieved of their dis- 
tention. The same events have sometimes arisen from excessive drink- 
ing of any liquid, but chiefly where the kidneys and the skin, the na- 
tural emunctories for superfluous fluid in the body, have failed in their 
office. Thus drinking largely of a cold liquid when the body is per- 
spiring and fatigued, weakens the heart's action, and checks the cuta- 
neous and renal secretion ; the blood-vessels become filled to tension, 
and may relieve themselves in dropsical effusions or diarrhcea. External 
cold sometimes operates in a similar way; it arrests perspiration, and 
causes internal congestions (§ 292) ; and if, from previous over-exeite- 
ment or other defect, the kidneys are unequal to perform what the skin 
fails to do, general fullness is the result, which tends to issue in some 
dropsy or flux. The sudden suppression of a cutaneous eruption, or of 
the discharge from an old ulcer, has sometimes been followed by anasarca, 
diarrhoea, or bronchial flux (humid asthma). The colliquative sweats 
of advanced phthisis are of the nature of a flux, by which the blood- 
vessels, in their obstructed and reduced state, relieve themselves of su- 
perfluous liquid. These sweats may generally be stopped by a judicious 
restriction in liquid food. 



182 



PROXIMATE ELEMENTS OF DISEASE. 



375. If we seek instances of local congestion terminating in flux and 
dropsical effusion, we easily find them in almost every variety of con- 
gestion that has been enumerated (§ 288, et seq.). In fact, these are 
the most common causes of partial dropsies. 

The adequacy of venous obstruction to produce dropsy, is well illus- 
trated by some experiments of Lower. He tied the jugular veins of a 
dog, expecting the animal to die of apoplexy; instead of this result, the 
face and head of the animal became much swelled with oedema. He 
then tied the ascending cava ; ascites and anasarca of the lower extre- 
mities were the results. Disease affords numerous examples of dropsy 
and flux from venous obstruction. Aneurisms of the arch of the aorta, 
or other tumors, by pressing on the venae innominatae, or descending 
cava, sometimes cause oedema of the face and upper extremities. In a 
case (under my care) of malignant tumor involving the roots of the lungs, 
there were hydrothorax, and flux into the bronchial tubes (bronchorrhoea). 
In advanced pregnancy and ovarian dropsy, the legs swell from pressure 
of the tumor on the iliac veins. Many instances are recorded in which 
occlusion of a large vein was followed by dropsy of the part from which 
the vein proceeded. The ascending cava has been found obliterated in 
persons who had long been affected with ascites and anasarca of the 
lower extremities. In the University College collection, there is a draw- 
ing of such a case, in which a supplementary circulation had been estab- 
lished by an enormous enlargement of the superficial veins of the abdo- 
men. Dr. Watson relates an instance of the same kind.* M. Tonnele 
has made some observations which favor the opinion, that chronic hydro- 
cephalus is caused by a partial obliteration of the venous sinuses of the 
head(§ 267). 

But the most common causes of venous obstruction, are certain vis- 
ceral diseases, and these commonly produce either dropsy or flux. Thus 
the contractile disease of the liver, cirrhosis, is the most frequent cause 
of simple ascites; and in connection with various functional and struc- 
tural diseases of the liver, diarrhoea and gastrorrhoea (watery eructations) 
are apt to occur. Structural disease of the heart, especially if seriously 
affecting the orifices or valves, commonly causes hydrothorax, bronchial 
flux (humid asthma), and sometimes general dropsy. Pulmonary con- 
gestion from causes impeding the respiration (§ 298), such as spasmodic 
asthma, emphysema, laryngitis, hanging, and coma, sometimes results 
in a bronchorrhoea or hydrothorax. In the experiments of Dr. J. Reid, 
a serous flux into the bronchial tubes ensued after the division of the par 
vagum, which, by impairing the respiratory action, 'induces pulmonary 
congestion.! 

376. As we found congestion to arise from weakness of the circulation 
and atony of the vessels (§ 290), so dropsical effusions and fluxes may 
proceed from the same causes. Thus oedema of the lower extremities 
is a common sign of extreme weakness ; as after severe illness, and to- 
wards the fatal termination of many chronic diseases. Colliquative di- 
arrhoea and perspiration (fluxes) sometimes occur under similar circum- 
stances. The oedema and fluxes, which arise from weakness, will be 

* Library of Medicine, Art. "Dropsy," vol. iii. 
f Edin. Aled, and Surg. Jour., yols, xlix^ li< 



FLUX AND DROPSY — PECULIAR CAUSES. 



183 



more readily induced by postures which cause gravitative congestion in 
the affected parts. Thus continued standing causes swelling of the legs, 
and leucorrhcea, in persons liable to these results of congestion. 

377. Fluxes and dropsical effusions sometimes occur after previous 
excessive excitement of the vessels of a part. Hence oedema after ery- 
sipelas, and the infiltration of serum in cavities and textures after exces- 
sive excitement of the vessels of these parts, even when no inflammation 
has been induced. The gleets or fluxes which follow inflammations of 
the urethra, bronchi, alimentary canal and vagina, seem to be connected 
with the same condition of the vessels that sometimes causes congestion 
(§ 294). Persons who indulge in spirituous liquors often suffer in the 
morning from waterbrash, for which they find a glass of spirits the best 
remedy: in this case, however, obstruction in the liver (§§ 56, 371) may 
also co-operate. 

378. Fluxes sometimes arise from the intropulsive operation of cold 
(§§ 77, 292); thus diarrhoea and catarrhal affections, too transient to be 
considered inflammatory, are frequently thus induced ; and diuresis (flux 
of urine) is a more healthy example of this effect of cold. It is doubtful 
whether this operation of cold will suffice to cause dropsy ; but it may 
increase it where it existed previously. 

379. The other variety of local hypersemia, determination of blood 
(§ 321), may produce fluxes and dropsies. The influence of various stimu- 
lants on secreting organs and surfaces, illustrates the production of 
fluxes in this way (§ 324). Thus, snuff in the nose determines a flow of 
nasal mucus and of tears; spices in the mouth provoke a discharge from 
the salivary glands ; irritating vapors inhaled cause a flux in the air- 
tubes ; purgative medicines induce a flux from the intestines, &c. In these 
cases, the irritation is short of inflammation, w T hich, although attended 
w r ith determination of blood and effusion, comprises further effects. The 
fluid thus secreted in these several cases of flux from determination of 
blood, differs from the products of inflammation : it commonly consists 
of the natural secretion of the part, diluted with an unusual proportion 
of w r ater and saline matter from the blood, and the excess of saline matter 
sometimes gives the secretion an irritating quality, as in the fluid of coryza, 
bronchorrhoea, and watery diarrhoea. 

Other examples of flux may be referred to determination of blood with- 
out special irritations; as the leucorrhcea which precedes and follows 
the menstrual period, the bronchorrhoea or gastrorrhoea in some cases 
excited by increased action of the heart, and the sweat succeeding to 
flushes of blood to the head or other parts. 

380. Dropsy is less frequently a result of simple determination of 
blood ; because, independently of inflammation, there are few causes for 
such determination to closed sacs. But probably the dropsy accompa- 
nying tubercles in the peritoneum and membranes of the brain, may in 
some degree be induced by the mechanical irritation of the tubercles 
causing a flow of blood to the membranes. The sudden mode of attack 
which tuberculous hydrocephalus sometimes exhibits, seems to counte- 
nance this opinion, being attended by the phenomena of determination 
of blood to the head, described before (§ 323), but here this proceeds to 
effusion of serum, with its more permanent symptoms. The kinds of 



184 



PROXIMATE ELEMENTS OF DISEASE. 



dropsy called inflammatory may be included under this head; but we 
shall shortly see that the determination of blood, or excitement of the cir- 
culation, present in such cases, is consequent on an altered condition of 
the blood itself. 

381. As flux and dropsy commonly arise from similar conditions of 
the vascular system, so they are sometimes found to succeed to one an- 
other. Thus Andral mentions a case in which hydrothorax was removed 
on the occurrence of a profuse flux from the air-passages. Examples 
are not uncommon of the subsidence of ascites on the occurrence of 
diarrhoea, or of the supervention of ascites, when a diarrhoea, of long 
duration, has been suddenly checked. Dr. Watson quotes from Dr. 
Farre's lectures, an instance in which hydrocele was removed by violent 
purging. It is a more familiar fact that the occurrence of dropsy is at- 
tended by a marked diminution of the urinary secretion, and that a free 
flow of this often reduces the dropsy. On a knowlege of the preceding 
facts may be founded the most effectual treatment of dropsy. 

382. Enough has been said to show that flux and dropsy, as well as 
hemorrhage, are occasional results of hyperemia in its different varieties. 
But what are the circumstances which determine the occurrence and 
kind of these results ? In the case of hemorrhage, we found the additional 
or determining cause to be in the vessels or in the blood (§ 350). So 
certain conditions of these favor the occurrence of flux and dropsy. An 
extreme amount of vascular distention will pretty certainly result either 
in rupture and hemorrhage, or in the exudation of the watery parts of 
the blood (§§ 305, 340), and the long continuance of congestion or ple- 
thora, by making the exhalation predominate over absorption, rarely fails 
to lead to similar consequences But in some cases, both dropsical effu- 
sions and fluxes take place with a facility disproportioned to the amount 
of hypersemia or to its duration ; and in these cases the cause may be traced 
to a generally lax, flabby state of the tonic and contractile fibre (§ 123), 
or to a poor watery state of the blood (§ 222), or to both these conditions 
together. Persons liable to these affections are usually of pale complexion 
and phlegmatic temperament (§ 40). 

The influence which relaxation of the solids has in producing proflu- 
vial and hydropic affections, is exhibited in the occurrence of these results, 
in parts after over-excitement (§ 294), where there is no indication of 
general disease of the blood. But in cases also in which the blood is 
diseased, there is usually a relaxed state of the vascular fibre ; and it is 
not easy to distinguish the separate influence of these causes. Thus the 
liability to dropsy and fluxes, after long fevers, defective nourishment 
(§§ 63, 196), or confinement in impure air, must be attributed to the 
joint operation of both classes of causes. 

383. The conditions of the blood tending to watery effusions, require 
further consideration. A poor or watery state of the blood, above noticed, 
is the most obvious of these ; and that this alone is sufficient, is plain, 
from the fact that injecting water in quantities into the veins of an ani- 
mal, will cause watery effusions or discharges, whilst the injection of 
blood or serum does not produce this effect. Persons who have lost much 
blood are liable to become dropsical from the same cause: the bulk of 
the lost blood is replaced by watery serum absorbed from various sources; 



FLUX AND DROPSY — CAUSES. 



185 



and thus the blood is in a diluted state (§ 264). The mode in which a 
watery blood tends to produce dropsy and flux, is not merely by the 
greater proneness of thin fluids to transude through the walls of the ves- 
sels, but also by the failure and irregular distribution of the force of the 
circulation. It has been already explained, under the head of ansemia 
(§ 262), that a scantiness of blood embarrasses the circulation. The 
structure of the heart, its valves and vessels, is adapted to certain degrees 
of spissitude and quantity of the blood ; and when these vary much from 
the natural standard, when the blood, instead of being of an unctuous 
fluidity, is watery and squashy, the hydraulic and moving apparatus of the 
heart and vessels is less capable of effecting its propulsion ; and this 
condition of the blood may thus not only facilitate watery effusions, but 
promote the congestions and other imperfections in the circulation with 
which flux and dropsy are commonly connected. 

384. Several of the circumstances which induce the thin state of the 
blood, have been already stated (§§ 222, 249, 382), and in its relations 
to dropsy, we would more particularly advert to imperfect excretion by 
the kidneys, liver, and skin, as the most common cause. In various 
forms of hypersemia, which lead to dropsy and flux, (plethora, conges- 
tion, and determination of blood,) it will be generally observed that 
these results ensue in proportion as the excreting organs fail, and that 
the removal of these results is to be effected chiefly by means which re- 
store or compensate the defective excretion. In many instances, ex- 
posure to cold has been followed by dropsy; and at first sight, this might 
seem to operate merely by checking perspiration, and thus retaining in 
the vessels water that should be eliminated, and which is then effused 
within the body. But checked perspiration alone will not cause dropsy : 
there must be a failure also in the action of the kidneys before this re- 
sult will ensue. If these act properly, checked perspiration may dis- 
order the circulation, and cause congestions, inflammations, and even 
fluxes ; but I have never met with a case of dropsy arising from expo- 
sure to cold, in which the urine was not diseased, and, in the great 
majority of instances, albuminous. 

The circumstances under which exposure to cold induces dropsy, are 
such as also impair the action of the kidneys. A man in a fit of intoxi- 
cation lies for several hours of the night on the cold damp grass; he 
arises much chilled, has shivering succeeded by fever, and general 
dropsy ensues: the urine is very scanty, and, on examination, is found to, 
be highly albuminous. The vital properties of the kidneys had been 
exhausted by the excitement of the stimulant beverage, so that when 
cold checks the perspiration, and throws the blood on internal organs, 
the kidneys cannot perform their vicarious action ; their vessels become 
distended with blood, and mechanically exude serum, instead of separat- 
ing the proper constituents of urine (§ 309); these and the superfluous 
water accumulate in the blood, and by their quantity and irritating quality 
cause effusions of serum containing urea in different parts of the body 
as well as various other functional disorders before noticed (§ 170). 

Another instance of a similar kind of general dropsy is that super- 
vening after scarlatina. This has been ascribed by some to a sub-in- 
flammation of the cellular texture, originating in the eruption ; by others. 



186 



PROXIMATE ELEMENTS OF DISEASE. 



to the diseased state of the skin, left by the eruption, suppressing the 
perspiration. But if either of these were the true cause, the dropsy 
ought to occur most in the cases in which the eruption is most abundant, 
which is by no means the fact; nay, I have treated several patients in 
whom anasarca followed a scarlatina fever, with sore throat, without any 
rash at all. But in all these cases the urine has been albuminous, which 
again shows that the diseased action of the kidney is the most essential 
lesion connected with general dropsy. How scarlatina impairs the func- 
tion of the kidney is a question too extensive to be discussed here ; but 
I will simply state my belief that it does so by causing in these glands 
a highly congested state, which injures their secreting power (§ 304), 
as a parallel effect is observed w T ith regard to the liver in bilious and in- 
termittent fevers. A female under my care with albuminuria, which 
was almost cured, was attacked with mild scarlet fever : the urine, which 
had been merely hazy by heat and nitric acid, now T became highly co- 
agulable, and continued so until the fever declined, w r hen the albumen 
again gradually decreased. 

The general dropsical state occurring towards the fatal termination of 
structural disease of the heart, I have in several cases found to be con- 
nected w r ith albuminuria and slight jaundice, and I have been long in 
the habit of pointing out these as the most surely fatal complications to 
which heart diseases naturally tend ; their connection has been before 
noticed (§§ 305, 309). 

385. The pathological effects of secretion of serous and scanty urine 
(oliguria) have been already described (§§ 170, 249), but we must advert 
to the mode in which it induces dropsy and flux. Where resulting from 
a suddenly operating cause, such as exposure to cold, or scarlatina, a 
febrile state is generally present, with a frequent and hard or sharp pulse, 
heat of skin, thirst, &c. These symptoms occurring in connection with 
anasarca, have led to the use of the terms inflammatory, febrile, acute or 
active dropsy; and so far as these terms only imply an excited state of 
the vascular system, they cannot be objected to. But some have em- 
ployed them to explain the cause of the dropsy, as if this proceeded 
merely from the excitement or inflammatory condition. That such a 
condition is present, is obvious not only from the febrile symptoms just 
mentioned, but also from the buffy state of the blood drawn, and from 
the dropsical effusions and fluxes being in many cases combined with 
the symptoms and products of inflammation. Thus the anasarca is often 
attended with great tenderness, and sometimes with an erysipelatous 
redness: swellings of the joints frequently have the character of rheu- 
matic inflammation; effusion in the abdomen and pleura is often accom- 
panied by pain or tenderness, and after death, slight deposits of lymph 
are found in addition to the serum ; catarrhal flux from the bronchi, and 
diarrhoea, are associated with symptoms of more irritation (spasm, con- 
striction, cough, vomiting, pain, and soreness), than occur with simple 
fluxes. 

Now, this inflammatory character may be readily explained, by refer- 
ring it to the irritating quality of the excrementitious matter which the 
failing function of the kidneys leaves in the blood. Under such circum- 
stances, urea has been found in the blood, and in various effusions 



FLUX AND DROPSY — CAUSES. 



1S7 



(§ 170), and may be fairly regarded as the materies morbi which irritates 
various parts, and from which, whilst the system seeks to relieve itself 
(§ 17), excitement and sundry effusions or discharges ensue. In two 
points, this condition resembles acute rheumatism (§ 351): — 1. In the 
number of parts which may be simultaneously or successively affected. 
2. In the want of any constancy in the seat of the affections. Both these 
points indicate that the cause is not essentially in any part, but in the 
blood. Another circumstance which approximates these affections to 
gout and rheumatism, is the nature of the excrementitious matter which 
accumulates in the blood. In the latter affections, there is good evidence 
that lithic and lactic acids are the chief ingredients of this matter (§ 256) ; 
but I have so commonly found an excess of urea in the urine of patients 
recovering from rheumatism, and the chief remedies for gout and rheu- 
matism so distinctly increase the elimination of this principle (§ 257), that 
we can scarcely doubt that, in these affections, nrea also is either pro- 
duced in excess, or insufficiently excreted. The proximity in composi- 
tion between lithic acid and urea, and the probable conversion of the for- 
mer into the latter (Liebig), should not be forgotten. Both gout and 
rheumatism, like oliguria, sometimes produce fluxes or catarrhal affec- 
tions. Lastly, the connection between these affections is apparent from 
the fact, that rheumatism is frequently complicated with albuminuria (as 
after scarlatina); and granular degeneration of the kidneys (Bright's 
disease) is apt to supervene in the most aggravated forms of rheumatism. 

386. But, besides the retention of excrementitious matter in the blood, 
there is a loss of albumen from this fluid. That this loss, by thinning 
the blood, facilitates dropsical and profluvial effusions, is most probable 
in all instances ; but this seems to be the especial cause of these results 
in the more chronic cases, and in the most anaemic subjects, for in these, 
as it has been already stated (§ 264), the blood is thinner, and more wa- 
tery, than in any other disease. Thus, in advanced stages of granular 
degeneration of the kidneys, and sooner in anaemic subjects, almost 
every congestion, or determination of blood, ends in watery effusion. — 
As the powers of the circulation fail, the effusion is connected chiefly 
with gravitative congestion (§ 291), and occurs most in the lower extre- 
mities; in this respect, differing from the dropsy of acute albuminuria, 
in which the swelling also affects the face, trunk and upper extremities. 
This form of dropsy is well entitled to the appellation — asthenic, or pas- 
sive, both from being connected with congestion and weakness of the 
circulation, and from the poor condition of the blood, and depressed or 
cachectic state of the functions dependent upon it(§§ 262, 185). 

387. From the preceding statements, it may be inferred that acute 
dropsy arises chiefly from the retention in the blood of excrementitious 
matter and water, which the kidneys fail to eliminate ; and that the more 
chronic or asthenic kinds, although often originating in the same way, 
are rather dependent on a poor or watery state of the blood, especially 
deficient in albumen (§ 222), This deficiency in many cases arises both 
from the continued drain by the loss of serum in the urine, and from the 
imperfect assimilation and nutrition connected with this state. But we 
have good evidence that the more chronic and asthenic forms of dropsy 
may arise from the same state of the blood, independently of disease of 



188 



PROXIMATE ELEMENTS OF DISEASE. 



the kidneys. Thus Andral and Delafond found dropsy in anaemic sheep, 
in connection with clistomata in the liver, only in those cases in which 
the albumen of the blood was below the natural standard. So, too, in 
the human subject ; the dropsy induced by very scanty or poor food, or 
close confinement in unhealthy places, or malarious districts, and that 
supervening in extreme states of debility or cachexia, are probably de- 
pendent, not merely on weak or obstructed circulation, but also on an 
impoverished condition of the blood itself. For the same reason, the 
various structural diseases which cause congestions, especially those of 
the heart and liver, often do not induce dropsy until the quality of the 
blood is impaired, either by imperfect excretion, or by inadequate nutri- 
tion. 

388. We have thus traced flux and dropsy in common, to elements 
previously considered, hyperemia in some of its forms, together with a 
diseased condition of the blood itself (§ 222), dependent on defective 
excretion (§§ 249, 250), or defective nutrition or assimilation (§ 268). 
The latter element, although not essential to the production of fluxes or 
local dropsies, is the chief cause of general dropsy, and constitutes the 
dropsical diathesis. If we endeavor further to distinguish between the 
pathological causes of flux and dropsy, we find from observation that 
flux more commonly results from determination of blood or congestion, 
with a lax state of the solids (§§ 123, 382), whilst dropsy is rather asso- 
ciated with the altered condition of the blood just noticed. 

389. The distinction just made between the causes of flux and dropsy, 
implies that flux is generally a more partial disease than dropsy, many 
circumstances relaxing the vessels of a part, without affecting the con- 
dition of the blood in the whole system. This is especially apt to occur 
in secreting organs and surfaces, which are, in fact, the common seat 
of fluxes. We have before noticed excessive secretion as a primary 
element of disease (§ 162), but the fluxes which we are now considering, 
consist less in excess of the natural secretion (although this often occurs 
also), than in the addition of a watery, saline, and sometimes albuminous 
fluid derived from the blood, a serosity in fact (§§ 305, 375). The 
fluids discharged in chronic coryza, bronchorrhcea, gastrorrhcea, and 
watery diarrhoea, are the natural mucus of the respective surfaces, much 
diluted with a thin serum, the saline matter of which often gives the 
secretion an irritating property. Sometimes this serous fluid is substi- 
tuted for the proper secretion, as in the coagulable urine of the more ad- 
vanced stages of Bright's disease. 

The circumstances which commonly induce flux in secreting surfaces, 
have been already noticed (§ 376, et seq.), but after a flux has continued 
for some time, it is apt to become habitual, apparently through perma- 
nent relaxation of these affected vessels. These become so weak, that 
any circumstance disordering the circulation may bring on an attack of 
the flux. In fact, the flux becomes an outlet for superfluous fluid in the 
blood-vessels, and for discharges which ought to be evacuated through 
the kidneys, skin, or bowels. 



FLUX AND DROPSY— TREATMENT. 



189 



GENERAL TREATMENT OF FLUX AND DROPSY. 

390. As there is much that is common to fluxes and dropsies, we may- 
abridge our notice of the remedial measures to be opposed to them, by 
first giving the treatment applicable to both, and afterwards specifying 
that indicated for each class of results. 

In so far as fluxes and dropsies depend on plethora, sthenic, or asthe- 
nic, congestion in all its varieties, or determination of blood, the reme- 
dies for these several morbid elements (§§ 283, et seq., 313, et seq., 342, 
et seq.), must form part of the treatment. So, also, according to the pre- 
valence of these constituent conditions, fluxes or dropsies may be more 
or less sthenic or active, or asthenic or passive, and more or less consti- 
tutional or local; and the treatment must be varied correspondingly. 
And according to whether these conditions are tractable or not, fluxes, 
and dropsies resulting from them, may be more or less difficult to remove, 
and exhibit many varieties as to duration and disposition to return. 
Thus fluxes and dropsies, w r hich arise from congestions caused by struc- 
tural disease of the heart or liver, or by tumors compressing veins (§ 375), 
although often removed for a time, are likely to return; but those arising 
from cold (§ 378), weakness (§ 376), previous excitement (§ 377), or 
functional disorder, may, in many cases, be cured permanently. 

391. We have repeatedly stated the circumstances under which vas- 
cular congestion or fullness in itself suffices to induce dropsy and flux 
(§§ 306,383); and under these circumstances, the remedies for con- 
gestion and plethora, are the first and most important to be used. Thus 
in dropsy or fluxes suddenly induced by structural disease of the heart 
and liver, often brought on by cold, over-exertion, or excitement, whilst 
the condition of the blood has not materially suffered, depletion, general 
or local, is advantageously premised before the use of other measures. 
Then follow remedies which, by increasing the secretions, reduce the 
remaining congestion and the effusions resulting from them: combina- 
tions of mercury or antimony with squill and digitalis are peculiarly 
serviceable in accomplishing this object. Various other means contri- 
bute to the same end, chiefly those which act as evacuants and deriva- 
tives. This treatment approaches to the antiphlogistic, as we have 
already found the nature and products of congestion of high tension, and 
of sthenic plethora, approximate those of inflammation (§ 307). But in 
the more peculiar causes of flux and dropsy — those that induce these 
results with slighter amounts of congestion or disordered circulation 
(§ 382) — those which constitute the dropsical and profluvial diathesis 
(§ 388) — we find conditions generally betokening weakness, and re- 
quiring a tonic or more supporting plan of treatment ; a relaxed state 
of the solids, and a watery condition of the blood. But even in the 
treatment of these cases, to derive from the weak or congested parts, 
and to increase defective excretions, are objects generally to be attempted. 
Further details will be better described under separate heads of flux and 
dropsy. 



190 



PROXIMATE ELEMENTS OF DISEASE. 



TREATMENT OF FLUXES. 

392. In all cases of flux, it is proper to derive from the affected part, 
and to promote the natural excretions in other directions, by some or other 
of the following means: warm bathing, warm clothing, exercise, friction, 
and stimulant applications to the surface, diaphoretic, diuretic, and ape- 
rient medicines. It is also necessary to avoid circumstances which pro- 
mote congestion or determination of blood in the affected part, such as 
dependent position, exposure to heat, cold to other parts, too fluid a diet, 
&c. In addition to these measures, it may be requisite to use others to 
counteract or remove the irritations or obstructions which the flux causes 
in the part which it affects. Thus demulcent and narcotic remedies are 
sometimes useful in catarrh and diarrhoea, to soothe irritation caused by 
the secreted fluid; at other times, expectorants and purgatives, to pro- 
mote its expulsion. 

393. The further treatment of fluxes will be guided by the state of the 
vascular function, whether sthenic or asthenic. As in cases of hemor- 
rhage, so with flux, it is sometimes attended by a hard, frequent pulse, 
heat of skin, and other signs of fever or of sthenic plethora: here eva- 
cuants, antimonials, sedatives, and even blood-letting, may be required. 
In fact, the disease borders on inflammation, and needs a similar treat- 
ment. Some cases of flux, of a sthenic character, arise from gouty or 
rheumatic matter in the blood: here colchicum and alkalies are the pro- 
per remedies, as they promote the removal of this matter by the kidneys. 
Others we have found to be connected with albuminuria (§ 380), and are 
to be treated as dropsy from that cause. In all these examples of sthenic 
or active flux, it is neither useful nor safe to attempt hastily to check the 
discharge by astringent remedies, lest the determination of blood attend- 
ing it end in a worse result, hemorrhage or inflammation. 

394. The majority of fluxes are, however, asthenic, connected with a 
weak state of the vessels, local or general ; and here other remedies are 
needful. Together with more or less of the general measures above de- 
scribed (§ 392), it is here safe and proper to endeavor to check the pro- 
fuse exhalation, by astringents, stimulants, and general tonics. Astring- 
ent remedies are most effectual by direct application: and their mode 
of action, by constricting the relaxed vessels (§ 388), is obvious. Thus 
acetate of lead, sulphate and acetate of zinc, sulphate of copper, nitrate 
of silver, alum, and some vegetable astringents, are effectual in leucor- 
rhcea and diarrhoea. Some of these remedies seem also to act through 
the medium of the circulation. Thus sugar of lead, sulphate of zinc, 
sulphate of copper, and mineral acids, given internally, sometimes dis- 
tinctly diminish bronchial flux and profuse perspiration, as we have al- 
ready found they sometimes arrest hemorrhage (§ 367). Some fluxes 
are remarkably checked by remedies whose operation seems to be rather 
stimulant than astringent. Thus spices, essential oils, and brandy, 
sometimes cure pyrosis and diarrhoea; cantharides diminish leucorrhoea; 
cubebs and copaiba, gonorrhoea; balsams of copaiba and Peru occasion- 
ally check bronchorrhoea. It is uncertain how these remedies operate ; 
but it is probably in removing congestions by causing determination of 



FLUX AND DROPSY TREATMENT. 



191 



blood, which excites contraction, and improved tone of the capillaries of 
the part(§ 317). They are most successful in asthenic cases originating 
from inflammation. Another remedy occasionally useful in controlling 
fluxes, is opium; its mode of operation is equally uncertain; but it is 
probably connected with its power to diminish natural secretions (§ 166). 
Its efficacy is most obvious in diarrhoea and diuresis; and it is sometimes 
beneficially combined with metallic astringents in bronchial and gastric 
flux. 

The state of the system in persons subject to fluxes is generally one 
of relaxation, and is therefore benefited by tonic medicines. Some of 
these have also an astringent property, which peculiarly adapts them for 
the treatment of asthenic fluxes. Thus the tincture of the sesquichloride 
of iron is useful in the treatment of leucorrhcea and humoral asthma, 
attended with much debility; infusion of cusparia in diarrhoea; and bark 
or quinine with mineral acids, gallic acid and tannin, in various fluxes 
in very relaxed habits. 

For similar reasons, the diet should be as generous as the digestive 
organs will bear; sometimes including animal food twice a day, and a 
moderate allowance of some sound fermented liquor. Excess in liquid 
food should be particularly avoided, especially tea, and warm slops 
generally. Catarrhal colds, which are acute fluxes, I am in the constant 
habit of curing simply by total abstinence from liquids during two or 
three days ; and although this extent of dry regimen is obviously inappli- 
cable to chronic cases, yet moderation in the use of liquids, especially 
before or during exposure to cold, is an important part of the treatment 
in all cases. I have known several instances of chronic coryza, bron- 
chorrhcea and diarrhoea kept up, if not brought on, by immoderate indulg- 
ence in tea and such liquids. These fluids cause a temporary plethora, 
which immediately finds vent through the lax vessels of the weak part 
(§ 389). The propriety of warm clothing, regular exercise, and a brac- 
ing, but not too cold an atmosphere, is obvious from the previous con- 
siderations. 

TREATMENT OF DROPSY. 

395. In addition to the means requisite to remove the variety of hy- 
persemia inducing the dropsy (§ 391), we have to remedy, as far as we 
can, those conditions of the blood which we have found (§ 384) specially 
to favor the occurrence of dropsy. Of the causes of these, a failure in 
the secreting power of the kidneys is the chief: its sign being a scanti- 
ness of the urine, a deficiency of the natural constituents of this excre- 
tion, sometimes with an accession of albumen. The treatment must, 
therefore, have regard to the condition of the kidneys, w T hich is the chief 
cause of this failure in their action, and to the state of the blood and 
other parts, which is the result of that failure. 

We have several times pointed out (§ 309) reasons for supposing a 
highly congested state of the kidneys to be the first cause of that failure 
in their function which induces albuminuria and its consequences. The 
means found most successful in removing dropsy arising from renal dis- 
ease, correspond well with this view. Thus in acute or inflammatory 



192 



PROXIMATE ELEMENTS OF DISEASE. 



dropsy, occurring after scarlatina, or exposure to cold (§ 384), blood- 
letting, especially by cupping to the loins, hydragogue purgatives, and 
diaphoretics, are advantageously used at first ; and subsequently some 
kinds of diuretic medicines, particularly tincture of cantharides, digitalis, 
and colchicum, sometimes restore the natural action of the kidneys. 
Such measures, if employed at an early period, before the disease in the 
kidneys has affected the structure, are often completely successful. They 
fulfil, not only the indication of diminishing the renal congestion, but 
that also of purifying the blood from excrementitious matter, and in re- 
ducing the sundry effusions, local irritations, and disturbances, which 
this matter excites in various parts (§ 385). They cure the dropsy by 
exciting artificial fluxes (§ 381). 

Of the hydragogue purgatives used in the treatment of acute dropsy, 
I have found cream of tartar in large doses (3'iv to £>x, every morning 
or every alternate morning), and extract of elaterium (J gr.), the most 
effectual. Tartarized antimony, alone, or combined with opium, is the 
best diaphoretic, and it often relieves the catarrhal symptoms commonly 
present. Care must be taken not to cause vomiting, to which there is 
often a natural tendency. Dr. Osborne recommends the vapor-bath, 
and Dr. Watson the hot-air bath, as means of deriving to the surface, 
and causing perspiration. After cupping to the loins has been repeated 
as often as the strength of the patient may indicate, in obstinate cases 
I have seen much benefit from blisters or other counter-irritants to the 
loins ; and in asthenic cases, which do not bear the loss of blood, large 
blisters may be used at first with great advantage. 

The dropsical effusions are often soon dispersed by the preceding 
measures; but the proof of the permanent benefit of the treatment is to 
be looked for in the progressive decrease of albumen, and the increase 
of urea and lithic acid in the urine. It often happens that, after the full 
use of depletion, cathartics, and diaphoretics, the condition of the urine 
becomes stationary, and does not advance towards a healthy standard. 
Then the diuretics before named are sometimes very effectual in 
augmenting the quantity of urine, without increasing the albumen in it; 
and where this is their first effect, their continuance will often produce 
a gradual diminution of the albumen. The tincture of cantharides is 
more powerful than the others in exciting the action of the kidneys; and 
where it increases the urine, the dose may be augmented from ^lx to 
^Ixx or 3ss thrice a day; but if the smaller dose do not act as a diuretic, 
it is not safe to proceed to the larger, nor, in fact, to persist with the me- 
dicine ; for if it irritates the kidneys without increasing their secretion, 
it is sure to do harm. We have noticed the same circumstance in the 
treatment of congestion by stimulants (§ 317) ; if they fail to remove 
the congestion, they aggravate the mischief. Digitalis and colchicum 
are safer diuretics, inasmuch as they are less irritating to the kidneys ; 
but they are also less powerful. 

Mercury might be expected to be useful in removing congestion or 
low inflammation in the kidney, and in restoring its secretion ; but it so 
speedily and severely salivates in such cases, without any equivalent 
benefit, that it is not generally eligible. The promptitude with which 
the gums are affected with mercur/ may be ascribed partly to the faci- 



DROPSY TREATMENT. 



193 



lity with which inflammations may be excited in any part (§ 385) ; and, 
in some measure, to the failing action of the emunctories of the system 
permitting the mercury to accumulate more speedily than usual (§ 260). 
But mercury is peculiarly efficacious in dropsy connected with diseased 
liver: and, in combination with squill, digitalis, and henbane, or conium, 
forms the most useful diuretic in all recent cases of dropsy dependent on 
congestion without disease of the kidneys. 

396. We have found (§§ 386, 387) that the asthenic forms of dropsy, 
and those of the most chronic character, are commonly connected with a 
watery, non-albuminous state of the blood, and general weakness of the 
system. To obviate this condition so far as possible by nourishing diet, 
tonics, and means to increase the strength, becomes here a leading indi- 
cation. In cases depending on malnutrition or mere debility (§ 387), this 
tonic and supporting treatment may be sufficient to effect a cure. In the 
commoner examples of dropsy, rendered asthenic by the long continuance 
of structural disease of the kidneys, liver, or other organs, the same 
strengthening and invigorating measures must be more or less combined 
w r ith means to excite the failing excernent organs, or to produce some 
compensating discharge. Thus in dropsy from chronic albuminuria, or 
advanced degrees of granular degeneration of the kidney, the occasional 
exhibition of hydragogue purgatives and diaphoretics, and of the diuretics 
before mentioned, is useful at the same time that bitters with iodide of 
potassium, or mineral acids, are given to keep up the general strength 
and powers of nutrition. In the more ansemic cases, iron is often of ad- 
vantage ; but it sometimes proves injurious by impairing the little secret- 
ing power remaining in the kidneys, and by rendering the urine more 
albuminous. Where it has this effect, its use must be abandoned. The 
preparations of iron that I have found most serviceable in these cases, 
are the ammonio-citrate in combination with iodide of potassium, and 
the muriated tincture. 

Asthenic dropsy arising from diseased liver is sometimes signally re- 
lieved by mercurial and diuretic medicines, followed by or even conjoined 
with calumbo, bark, and other vegetable tonics. In several cases under 
my care, ascites, of great extent and long duration, connected with gran- 
ular degeneration (cirrhosis) of the liver, has been removed, and the 
patients have been for a time restored to apparent health, by a course of 
hydragogue doses of cream of tartar every morning, or every other morn- 
ing, with bark and nourishing diet in the day. Hydragogue purgatives 
are more directly useful in removing ascites connected with diseased 
liver, inasmuch as they excite a discharge from the congested vessels 
themselves, and substitute 'abdominal flux for abdominal dropsy (§ 381). 
But they often fail to excite a watery discharge from the intestines, and 
instead cause much irritation, with tenesmus, and slimy or bloody stools: 
under these circumstances they must be discontinued ; but after blister- 
ing the abdomen, or applying leeches to the region of the liver, or to the 
anus (§ 319), and interposing a gentler but more searching aperient con- 
taining mercury, the useful operation of hydragogue purgatives may 
sometimes be again obtained. Similar means will often facilitate the 
operation of diuretics. Dr. O'Beirne has argued strongly in favor of 
blood-letting in dropsy, under the impression that by relieving the pres- 
13 



194 



PROXIMATE ELEMENTS OF DISEASE. 



sure from congested blood-vessels, it enables secreting organs to act. 
(Dublin Journ. of Med. Sci., Nov. 1842.) Like most other writers on 
dropsy, Dr. O'Beirne does not seem to me sufficiently to regard the 
mixed character of the disease. 

397. The tendency of dropsy connected with diseased heart, kidneys, 
or liver, to recur again and again, and become chronic, renders it need- 
ful to vary as much as possible the remedies employed, as well as to use 
means to support the strength. It is an important point in the treatment 
of such cases not to exhaust the powers of any secreting organ by too 
long acting on it, and not to expend the efficacy of any one remedy by 
too long continuing its use. By employing sometimes diuretics, some- 
times purgatives, sometimes diaphoretics, and by aiding each of these 
by local depletion or derivants, or by stimulants and tonics, according to 
the temporary prevalence of vascular fullness and excitement, or the 
converse, much may often be effected to prolong life. It is in the appli- 
cation of these rules to the treatment of prolonged cases, that the skill 
and resources of the rational practitioner are most tried, and his supe- 
riority over the routinist is best proved. It is under these circumstances, 
too, advantageous to have at command a great variety of medicines, 
particularly diuretics, and to alternate them or vary them in order to in- 
crease or maintain their effect. Those that I have found most effectual 
are — combinations of mercury, squill, digitalis, and conium (not in acute 
albuminuria); combinations of decoction of broom, or pyrola umbellata, 
with nitrate and acetate of potass; the juice or extract of taraxacum, 
with the same salts or bitartrate of potass, or with nitric acid (particularly 
in hepatic disease) ; infusion or tincture of digitalis, with iodide of pot- 
assium, and bitartrate of potass (in dropsy after scarlatina); the same, 
together with increasing doses of tincture of cantharides (in asthenic 
cases of albuminuria, after cupping to the loins and hydragogue purga- 
tives) ; ammonio-tartrate and ammonio-citrate of iron in Seltzer water 
(in asthenic dropsy); gin in cream of tartar beverage (imperial); com- 
pound spirit of juniper, spirit of nitric aether, with various others (in 
cases of debility). The latter stimulant diuretics have disappointed me 
more than any of the rest. 

398. When dropsical swellings have reached a certain amount of 
tension, diuretic and other remedies produce little or no effect on them. 
The veins and lymphatics, whose office it is to remove these swellings, 
are too much compressed to be capable of absorbing. In the case of 
ascites, this pressure impedes the circulation through the kidneys and 
intestines, and their secretions are proportionally reduced (§ 159). Ex- 
tensive hydrothorax, and even ascites, in a similar way embarrass the 
functions of the lungs and heart. Anasarca, in its extreme degrees, 
sometimes impedes the circulation in the vessels of the lower extremities, 
so far, as not only to prevent absorption, but even to cause the death of 
the parts; hence gangrene of the legs is a common termination of incur- 
able dropsy. The gangrene is commonly preceded by an erysipelatous 
kind of inflammation, which often seems to originate in some accidental 
scratch, or from the irritation of mechanical tension, or of the quality of 
the effused fluid. 

Now, in all these cases, the great expedient is to give exit to a portion 



INFLAMMATION — : 



NAME AND DEFINITION. 



195 



of the fluid, by tapping or puncturing the parts which contain ft. Thus 
the abdomen is tapped for ascites; the chest for hydrothorax ; the scrotum 
for hydrocele; the brain for hydrocephalus; ovarian and other cysts, 
when they attain a large size ; and the legs are acupunctured for anasarca. 
The relief afforded by these means is sometimes very remarkable, even 
when much fluid is left unremoved. In fact, the great utility of these 
operations seems to consist in the removal of an amount of pressure and 
distention that was seriously impeding the functions of the several parts. 
Accordingly we find, after these operations, not only a great mitigation 
of suffering, but a restoration of the functions of circulation, secretion, 
respiration, &c, which before were mechanically obstructed. After para- 
centesis, diuretic and other remedies regain their power, and contribute 
to reduce the remaining effusion; and the secretions being free, the pa- 
tient is able to bear nourishing food and strengthening remedies, which 
previously would have increased the excitement and oppression. 

The usual indications for the use of these surgical resources are, an 
amount of dropsical effusion which seriously injures the functions of cir- 
culation, secretion, or respiration, other remedies having failed to give 
relief. Under such circumstances the operation should not be delayed. 
In puncturing the legs for anasarca, it is proper to bear in mind the 
tendency to low inflammation and gangrene, and to avoid this, the skin 
and flesh should be injured as little as possible; numerous punctures 
should be made with a fine needle, but not too close together; and inas- 
much as there is more tendency to this result where the circulation is 
weakest and most remote from the heart, it is better to avoid puncturing 
below the knees. 

Further details on these subjects properly belong to special pathology, 
and would be out of place here. 



SECTION VII. 

LOCAL HYPEREMIA. EXCESS OF BLOOD IN A PART. 

III. WITH MOTION PARTLY INCREASED, PARTLY DIMINISHED == 
INFLAMMATION. 

DEFINITIONS. 

399. The morbid conditions connected with the quantity and motion 
of the blood hitherto described, have been pretty distinctly defined; and 
we have been able to refer many phenomena of disease to them. We 
now come to one, the name of which is very familiar, and its frequency 
gives it so high an importance, that it has always attracted the first 
attention of pathologists: but although so commonly occurring, it is much 
more complicated in its nature than any of the morbid elements pre- 
viously considered; in fact, it may be said almost to comprehend them 
all, besides being a still further deviation from the natural condition, 



196 



PROXIMATE ELEMENTS OF DISEASE. 



The terms inflammation, phlegmasia, and phlogosis, have been used, 
from a very remote period, to denote figuratively the heat, redness, and 
burning and painful sensations which commonly exist in inflamed parts. 
The occurrence of inflammation is so common, and its more prominent 
symptoms so familiar, that it has long been distinguished as a chief 
element of disease; in fact, it has, in a measure, engrossed the attention 
of pathologists so entirely, that other important elements have been 
almost overlooked; and this oversight has not only retarded the advance- 
ment of our knowledge with regard to these other elements, but it has 
rendered the subject of inflammation itself less intelligible, by excluding 
the consideration of some of its component parts, and by keeping it in 
all its complexity and remoteness from the normal conditions of function 
and structure. We shall find, that an acquaintance with the ultimate 
and proximate elements of disease, already considered in this work, is 
essential to the proper understanding of the nature of inflammation; for 
these form the connecting link between the natural properties of living 
textures, and their extreme variation in the state of inflammation. The 
pathological definition given above to distinguish inflammation from the 
other varieties of hyperemia — too much blood in a part with motion (of 
that blood) partly increased partly diminished — is easily demonstrated in 
the strong pulse of arteries leading to an inflamed part, and in the stag- 
nation of much blood in the part. 

400. But besides this pathological definition, its outward characters 
may be briefly defined in the four signs which, from the time of Celsus, 
have been considered distinctive of inflammation, redness, heat, pain, 
and swelling. These signs are sometimes produced by congestion (§ 303), 
and by determination of blood (§ 333, &c); but in a degree less marked, 
and for a time less continued, than in inflammation; and although there 
are cases and forms of inflammation in which it is not possible to detect 
all these marks, they may still be said to constitute its most general cha- 
racter. In common with other varieties of local hyperemia, inflamma- 
tion owes the sign of redness to the excess of blood in the part, but we 
shall find that this redness is heightened by a peculiar concentration of 
the particles in the inflamed vessels, which is also the cause of the 
peculiar results of the process. As in determination of blood, the heat 
and pain are in part due to the increased motion of the blood; but in 
inflammation, they are exaggerated by the motion being opposed to 
obstruction. As with other forms of hypera?mia, the swelling arises 
partly from the over-distention of the blood-vessels, and partly from 
effusions from them ; but in these effusions, inflammation differs from 
congestion and simple determination, departing still further than these 
from the natural quantity and quality of the effused matters. 

CAUSES OF INFLAMMATION, AND THEIR MODE OF OPERATION. 

401. Predisposition to inflammation has been already noticed under 
the head of predisposing causes of disease (chap, i., sect. 2). The cir- 
cumstances which render the body liable to inflammation, are those which 
especially affect the vascular system, whether these circumstances be the 
result of original conformation, as the sanguine temperament (§ 38) ; or 



INFLAMMATION — CAUSES. 



197 



whether they be the effect of previous disease (§ 31), of present disease 
(§ 34), or of external or internal causes in actual operation (§ 20, et seq. 
30). Inasmuch as various circumstances, external or internal, tend, 
generally or locally, to impair the healthy tone and balance of the vas- 
cular system (§ 123), whilst muscular irritability (§ 112) and the quantity 
of the blood are not proportionately reduced (§ 195), so far they predis- 
pose to inflammation. Accordingly, we find persons prone to inflammation 
to be those whose circulation has been weakened or irregularly excited 
by previous disease, fatigue, confinement, impure air, or improper nour- 
ishment. But it will presently appear, that predisposition to inflamma- 
tion differs, according to the nature of the cause which excites inflam- 
mation; those most subject to inflammation from causes acting generally, 
suffering less than others from causes which act only locally. Thus, a 
depressed state of the whole vascular system, favors the production of 
inflammation from causes acting generally (such as cold); whereas, an 
excited state of the vascular system favors the development of inflamma- 
tion from local irritation. 

402. The concluding part of the last paragraph prepares us to divide 
the exciting causes of inflammation into those which act locally on the 
part which inflames, and those which act more generally on other parts. 
The operation of the first class is direct ; that of the second is indirect, 
therefore, less certain, and more dependent on predisposition. 

The local exciting causes of inflammation comprehend irritants, me- 
chanical, chemical and vital. A grain of sand in the eye, a thorn in the 
true skin, and a bruise or wound in the flesh, are examples of mechani- 
cal irritants, or sources of irritation. Chemical irritants are those which 
operate on living matter by strong chemical affinity, tending to alter or 
decompose it (§ 53) ; such are heat, strong acids and alkalies, various 
corrosive salts, chlorine, iodine, &c. ; these act also on dead textures. — 
Vital irritants are various agents whose irritating operation is not refer- 
able to any known chemical property, nor do they act on dead animal 
textures; of this kind are cantharides, mustard, capsicum and essential 
oils. In this last class must be included various animal and vegetable 
irritant poisons; such as that of small-pox, and the venom of some nox- 
ious animals and plants, which act as local irritants, besides otherwise 
affecting the system. Various noxious matters, sometimes generated in 
the living or recently dead body, are also capable of exciting inflamma- 
tion when applied to an abraded surface (§ 258). Nay, the natural ex- 
cretions of the body become most acrid irritants, when brought into con- 
tact with serous membranes; thus urine, feces and bile, effused in serous 
membranes, even in the smallest quantities, produce intense irritation and 
inflammation. 

Irritation and inflammation are sometimes caused by excrementitious 
matter retained in the blood, where the functions of the excernent organs 
are impaired (§§ 249, 251, 254). Local inflammations are also excited 
by certain poisons received into the system ; thus arsenic, even when 
applied to a wound, causes inflammation of the stomach and intestines; 
mercury excites inflammation of the gums ; the poisons of small-pox, 
scarlatina and measles, inflame the skin, throat and air-passages ; that 
of syphilis, the periosteum, throat, skin, iris, &c. In these cases, there 



198 



PROXIMATE ELEMENTS OF DISEASE. 



can be little doubt that inflammation is excited by the actual presence 
of the peculiar irritating matter in the parts which inflame, conveyed 
there in the blood; and it is a leading character in the operation of these 
irritants which are conveyed through the blood, that it affects several 
parts, or a considerable portion of the body at once ; and frequently, the 
two sides of the body in a similar manner. This is observed in the 
eruptions of exanthematous and other skin diseases, in rheumatism, in 
syphilitic nodes, &c. (§ 259). 

403. The second class of causes exciting inflammation, those which 
operate indirectly, are of very common occurrence; and, although com- 
prising fewer agents, they as frequently produce diseases as the more 
direct causes of irritation. They include those which first produce 
congestion, which, on the occurrence of subsequent reaction, is converted 
into inflammation. The most common of these causes is cold, which, 
both by its local operation (§ 76), and by its more general application' 
(§ 77), may produce congestions (§§ 296, 292), which may pass into 
inflammation. Malaria, and the influences which induce continued and 
eruptive fevers, as they produce congestions (§ 293), so they often lay 
the foundation of inflammations, w T hich complicate the febrile affections 
excited by these causes. Inflammations sometimes arise out of the 
congestions caused by venous obstruction (§ 289) and gravitation. Thus 
pneumonia (with hepatization, and sometimes suppuration) frequently 
occurs in connection with disease of the heart, impeding the circulation ; 
in adynamic fevers, and in the sinking which precedes death (§ 290). 
The congestions of the lungs, brain, and mucous membranes, that result 
from the application of various asphyxiating causes (§ 298), sometimes 
end in inflammations, which become a chief source of danger after the 
restoration of the respiration (§§ 235, 243). 

404. Suppression of natural or habitual discharges, especially the 
catamenia, the sudden drying up of ulcers, and repulsion of cutaneous 
eruptions (§ 69), are recognized as causes of inflammation (§ 67). So far 
as the inflammation excited by these causes is in, or contiguous to, the 
parts previously affected, local irritation may have a share in producing 
it ; but where it is in distant parts, it probably results from a congestion 
or local determination of blood, which belongs to the second class of 
causes just specified. Very probably some of these causes of inflamma- 
tion have a twofold operation, that just specified (producing a local 
fullness), and that of local irritation by morbid matters introduced into 
the circulating mass of blood. Thus the visceral inflammations arising 
on the sudden healing of a suppurating wound may be promoted by 
local congestions resulting from the cessation of the purulent discharge ; 
but their circumscribed character, and the uniform event to which they 
tend (suppuration), seem to indicate a morbid matter in the circulating 
blood as the exciting cause of these inflammations, and microscopical 
researches have confirmed this inference. The same remark will apply 
to the inflammations of the skin, fauces, and mucous membranes in 
scarlatina, measles, and small-pox; the follicular enteritis of typhus,* 

* I have observed an extraordinary development and inflammation of the isolated and 
grouped glands of the intestines in the bodies of persons poisoned with arsenic. Their en- 
largement in epidemic cholera, and in the severe form of sporadic cholera, diarrhoea, and 



INFLAMMATION OPERATION OF CAUSES. 



199 



and the visceral complications of erysipelas, and other specific febrile 
affections. In all these, besides a general tendency to internal conges- 
tions, we seem to trace the irritating operation of a morbid poison on 
particular parts. 

405. We have noticed that sthenic hemorrhages (§ 363) and fluxes 
(§ 393), if too speedily checked without sufficient reduction of the circu- 
lation, are apt to pass into inflammation. So likewise determination of 
blood, if it be long continued, may issue in inflammation (§ 340). The 
causes which excite determination of blood, when applied in a greater 
degree, or for a longer time, excite inflammation. 

406. Before we proceed to examine into the nature of inflammation, 
we may properly inquire what is the mode of the operation of its causes. 
It is generally assumed that the first movement of inflammation, as of 
all pathological processes, is in the nerves; but this is by no means 
proved. That some causes of inflammation (irritants) operate first on the 
nerves, is probable from the following considerations. 1. Their action 
on the sensitive nerves is felt long before inflammation begins; thus the 
prick of a thorn in the skin, the smarting of caustic on a wound, the 
pain of the sting of an insect, are felt instantaneously; there is first 
nervous irritation ; inflammation follows after. 2. The irritation is some- 
times transferred to other parts by sympathy, of w r hich nerves are the 
channels: thus strong irritants in the nostrils may cause inflammation 
of the conjunctiva, a carious tooth or a diseased bone may irritate and 
inflame parts which are not contiguous to it. 3. An injury to a nerve 
is.sometimes followed by inflammation in parts connected with this nerve. 
Thus paralyzed limbs are liable to become inflamed. Lallemand relates 
a case in which a ligature, involving the right brachial plexus, was fol- 
lowed by inflammation and suppuration in the opposite hemisphere of 
the brain. 

407. On the other hand, the following arguments may be adduced to 
show that the nerves are not essentially the seat of the first part of the 
process of inflammation. 1, Some of the causes of inflammation (the 
majority of those inducing internal inflammation) produce on the nerves 
or nervous system no know r n primary effect, w T hich resembles that of other 
causes of inflammation (irritants): thus inflammations excited by cold 
are often preceded by no marked nervous disturbance; whereas the 
strongest impressions of cold on this system are frequently not followed 
by inflammation (§ 77). 2. Inflammations often originate in congestions 

dysentery, caused by putrid effluvia, is well known. Are these glands excretory organs for 
the elimination of poisonous or noxious matters from the system? and in typhus fever, do 
they become inflamed and ulcerated by the continued operation of the poison in the exer- 
cise of this function? The favorable influence of moderate diarrhcea in fever, the uncom- 
mon fetor of the stools, the general relation between the duration of the fever and the affec- 
tion of these follicles, the salutary operation of mild mercurial remedies, which promote 
their secretion, and other facts that might be adduced, give so much countenance to this 
question, as to make it worthy of attention. 

The preceding surmise, put forth in the first edition of this work, has received corrobo- 
ration from numerous facts which I have subsequently observed, and it seems to me to 
indicate the true cause of the intestinal complication in fevers and other diseases induced 
by a morbid poison in the system. Dr. Carpenter has recently advocated this opinion, and 
further applied it to account for the fetid and colliquative diarrhoea which often occurs in 
states of much depression. (Human Physiology, [p. 670, 3d Am. Ed.]) 



200 



PROXIMATE ELEMENTS OF DISEASE. 



(§ 403) and in the sudden suppression of hemorrhages and other dis- 
charges (§ 405), without the occurrence of any symptoms referable to 
the nerves: hence inflammations thus arising may escape detection, and 
are called latent. 3. Persons in whom nervous properties are most de- 
veloped (§§ 126, 152, 156) are not those most susceptible of inflamma- 
tion; and all varieties of nervous excitement are sometimes manifest in 
the highest degree without any inflammation ensuing. Even where pain 
and other nervous symptoms are excessive, and are the result of mechan- 
ical or chemical injuries (such as crushed limbs, extensive burns, &c), 
inflammation sometimes does not follow; and this has led surgeons long 
to distinguish between irritation and inflammation. 4. Inflammation 
readily occurs in parts, the nerves of which are paralyzed or have been 
divided.* 

408. Seeing, then, that inflammation is frequently excited without any 
obvious affection of the nerves, and is often not excited-w T hen nervous 
irritation is most intense, it may fairly be inferred that an impression on 
the nerves is not an essential part of the first process of inflammation. 
That the nerves are concerned in many ulterior phenomena of inflamma- 
tion, and in its extension, is fully admitted: and in the case of excite- 
ment of inflammation by irritation, the primary operation of the exciting 
cause on the nerves has been already pointed out (§ 406). So far as is 
known, the blood-vessels are the essential seat of the whole process of 
inflammation; and although some of the exciting causes of inflamma- 
tion (§ 402, irritants) act on the nerves as well, yet others (§ 403, as cold) 
operate chiefly and essentially only on the blood-vessels. Hence we find 
that the causes predisposing to inflammation (§ 401) are circumstances 
chiefly affecting the vascular system. A review of the exciting causes 
of inflammation (§§ 402, 405) will show that in their mode of operation 
on the blood-vessels they may be divided into two classes: 1, those that 
cause determination of blood (§§ 322 — 324); and, 2, those that produce 
congestion (§§ 290 — 299). The former class comprehends all irritants 
(§ 402); the latter class includes cold and other agents, which directly 
produce congestion (§§ 403, 405). We have several times had occasion 
to mention that determination of blood, when exceeding certain limits, 
is apt to pass into inflammation (§ 340); and that local congestions are 
liable to be converted into inflammation (§§ 292, 293, 306). 

PHENOMENA AND NATURE OF INFLAMMATION. 

409. Having noticed the causes of inflammation, and traced their es- 
sential operation to be on the blood-vessels and their contents, we have 
next to inquire what is the character of their operation on the vessels, 
and what phenomena it develops. 

That the blood-vessels are enlarged in an inflamed part is very obvious 

* It is maintained by Dr. Copland and others, that in these cases, branches of the gan- 
glionic system distributed on the coats of the blood-vessels, are the first subjects of excitement. 
This hypothesis gives no aid in the explanation of the phenomena, because nothing is defi- 
nitely known as to the properties communicated by ganglionic nerves. Before the ''influence 
of the ganglionic system" can be employed as an element in pathology, its existence must 
be proved, and its properties defined, in physiology; this has not been done. 



INFLAMMATION NATURE AND PHENOMENA. 



201 



from the increased redness manifest to the naked eye. But in what respect 
does inflammation differ from congestion, in which also the vessels are 
enlarged? It differs not only in the accompanying symptoms and in its 
products, but also in the observed condition of the vessels of the part. 
Thus besides greater pain and heat in an inflamed part, and earlier and 
more abundant effusions into or from it, the more florid hue of redness, 
the strong beating of the arteries leading to the part, and augmented* 
quantity of blood flowing from its veins, clearly indicate that there is 
increased motion of the blood, instead of diminished motion, as in con- 
gestion (§ 287). 

Common observation of the pulse of arteries leading to inflamed parts 
would suffice to show that there is determination of blood to them; and 
some experiments performed by Dr. Alison and others have directly 
proved that these arteries are enlarged.* It was found that the arteries 
leading to an inflamed limb in a horse were considerably larger than those 
of the sound limb. John Hunter had arrived at the same conclusion 
from experiments on the ears of a rabbit. Now this enlargement has 
been before traced to diminished tonicity in the affected arteries, and this 
was found to be the chief instrument in causing determination of blood 
(§§ 326, 327). ; 

That the motion of the blood is increased through an inflamed part, is 
distinctly proved by the observation of Mr. Lawrence; venesection being 
performed at the same time, and in the same manner, in both arms of a 
patient who had an inflammation in one hand, a much greater quantity 
of blood flowed from the vein of the arm of the inflamed hand than from 
that of the other arm. 

410. It is certain, both from the preceding facts, and from direct ob- 
servation under the microscope, that determination of blood is present in 
inflammation. The vessels in the vicinity of the inflamed part are the 
channels of an increased flow, there being a flux of blood to the whole 
inflamed part, and through some of its vessels. But if this w T ere all, 
there would be no distinction between determination of blood and in- 
flammation; yet the greater redness and swelling, and peculiar character 
of the effusion point out that inflammation is not mere determination. 
Microscopic research has established one great point of difference. The 
observations of Thomson, Hastings, Kaltenbrunner, and Marshall Hall, 
have long clearly proved that there is more or less obstruction to the pas- 
sage of the blood in the vessels most inflamed. Thus in the frog's web, 
when a part inflames from local irritation, the blood is seen to move more 
slowly in the part most irritated, and gradually accumulating in the ves- 
sels, renders them larger, redder, and more tortuous, until the motion 
ceases altogether in them, whilst neighboring vessels are still the channel 
of an increased current. A chief point then in which inflammation dif- 
fers from determination of blood, is in the retarded or arrested flow of 
blood in some of the vessels. This answers to the definition which we 
have given of inflammation: too much blood in a part, with motion [of 
that blood) partly increased, partly diminished (§ 399). 

411. The question now naturally arises — What is the cause of the 



* Trans, of British Association, 1835. 



202 



PROXIMATE ELEMENTS OF DISEASE. 



obstructed or retarded flow of blood through an inflamed part? This 
has ever been the chief difficulty in the pathology of inflammation; and 
it is especially to solve this that various hypotheses have been framed. 
Thus Cullen supposed a spasm of the extreme vessels to be the cause of 
obstruction, and therefore the proximate cause (§ 13) of inflammation. 
Dr. Wilson Philip ascribes the same obstruction to a weakness of the 
^capillaries which he presumes to incapacitate these vessels from trans- 
mitting the blood. John Hunter considered that there is something more 
active and vital in the enlargement of inflamed vessels, and he applied 
to it the term "active dilatation." The analogous expressions, "vital 
tumescence," "turgor vitalis," "inflammatory erection," used by Kal- 
tenbrunner and other German writers, imply a similar notion. 

The hypothesis of Cullen is quite inconsistent with direct observation, 
the extreme vessels being seen, under the microscope, to be in a state 
of dilatation, not of spasm. This observation corresponds better with 
the idea of Dr. W. Philip, which was, indeed, founded upon it ; but it 
has been objected by Dr. Marshall Hall, and others, that the capillaries, 
by their contraction, do not aid in the circulation of the blood, and that 
their " debility," therefore, cannot be a sufficient cause for interrupted 
passage of blood through them. The words used by Hunter scarcely 
convey any explanatory meaning. They may be interpreted to assume 
the existence of a self-expansive power in the vessels, which power is 
supposed to act in inflammation, as well as in natural formative or plas- 
tic processes in the animal body. But the existence of such a power is 
quite at variance with all that is known of animal physics. A part may 
be expanded by elasticity, or by the injection or retention of fluid in it, 
but no direct vital expansile power has been ever proved to exist. The 
apparently active expansion of the heart in its diastole, may be ascribed 
to the natural elasticity of the organ, and the increasing weight of its 
contents, suddenly enlarging its size on the cessation of its antagonizing 
systole; neither its structure nor its mode of action countenances the 
notion of a vital dilating power. 

412. Haller, and some of his followers, ascribed the circulation of 
the blood, in part, to certain supposed properties of vital attraction and 
repulsion, by which the blood is drawn into, or repelled from, particular 
parts, independently of all motion of the living solids. These opinions 
have been recently advocated, with much ability, by Dr. Alison and 
some of his followers, who consider changes in these assumed vital at- 
tractions and repulsions, to be the chief elements in the process of in- 
flammation, as well as in other pathological conditions in which the 
blood and its vessels are mainly concerned.* This hypothesis needs the 

* See Alison's " Outlines of Pathology and Practice of Medicine." Several of Dr. Ali- 
son's arguments in favor of the existence of "vital attractions and repulsions," are founded 
on certain physiological facts, which he considers inexplicable in any other view. — 
It belongs properly to works on physiology to discuss these matters; but I must own that 
none of these arguments seem to me to be satisfactory. The motion of the sap in the chara 
and other vegetables, may be well explained on the principle of exosmosis and endosmosis. 
A fluid of lower density, (water,) physically tends to penetrate and pass into membranous 
tubes, containing a liquid of greater density, (sap ;) that which begins a flow into the tubes, 
may sustain it in continued current through them, so long as the difference in density subsists 
between the water and, sap. A similar principle doubtless aids, in many cases, the motion 



INFLAMMATION — NATURE AND PHENOMENA. 



203 



most ample proof before it can be received. It assumes the existence, 
in the fluids, as well as in the solids, of the living body, of properties as 
distinctive, and as peculiarly vital, as that of contractility or sensibility. 
It ascribes to these fluids and solids, powers of attraction and repulsion 
at sensible distances, like the attractions and repulsions of electricity, 
magnetism or gravitation, yet distinct from all these, and sometimes op- 
posed to them. It attributes to the living body a new physical power, 
and almost a discerning intelligence in the exercise of that power. Now, 
before the existence of such a power can be admitted, it must be proved 
that the phenomena of living structures are not, and cannot be, explained 
through any known vital or physical agencies. We have already ad- 
duced and referred to arguments and observations, to show that the known 
physical and vital properties of the living body will account for the chief 
phenomena of health and disease, without assuming the existence of any 
forces of a mysterious character ; and we have now to consider whether 
the same thing may be done with regard to inflammation. If we suc- 
ceed in explaining the nature and effects of inflammation by a reference 
to ascertained properties, it will be needless and unphilosophical to as- 
sume the existence of others, which are mysterious and unknown. We 
do not pretend to propose these explanations as complete or certain, but 
as the best that we can devise in the present state of science, and the 
most consistent with well-established facts ; and it is very satisfactory 
to observe, that the discoveries in chemical physiology made since the 
first edition of this work was written, so far from invalidating these views 
on the nature of inflammation and its results, go far to confirm and ex- 
tend them. 

of fluids in the animal body; but many motions of fluids observed in animals (as in the 
air tubes, genito-urinary passages, &c.) have been traced to the vibrations of cilia, and are no 
proof of the existence of vital attractions and repulsions. 

It is said, that, when an artery is tied, the blood ceases to run in the open part of it, and 
passes away by adjoining branches, which become enlarged in proportion, whilst the tied 
portion becomes empty. It has been supposed that the blood here spontaneously leaves the 
part of the artery through which there is no passage. I demur to the correctness of the 
statement, and still more to the explanation. Every one who has witnessed great surgical 
operations, must have noticed the strong pulsation above the ligature of tied arteries ; and 
the occasional occurrence of secondary hemorrhage, shows that the blood has no inherent 
disposition to pass in a new direction. No doubt, in time, the artery ceases to receive blood 
into its tied portion; but this is because either a coaguium is formed where a current cannot 
pass, or the tonicity of this portion effects the contraction of the tube, the force of the circu- 
lation being diverted into the contiguous enlarged branches. Here is no proof of any 
selfmotory and self directing power in the blood. I have before stated, that all my own 
microscopic observations have failed to detect in the blood any spontaneous motions, inde- 
pendent of contractions of the solids, or of currents, caused by ciliary motion, exosmosis and 
endosmosis, and such physical influences. The oscillatory motion said to have been seen by 
Haller and Kaltenbrunner in the small blood-vessels of inflamed parts, " even after the heart 
is at rest," may, perhaps, be ascribed to the tonic contraction of the arteries, which, although 
gradual in itself, is often seen to act by jerks on partially obstructed vessels. A similar os- 
cillatory movement is sometimes communicated to capillary vessels by the quivering con- 
traction of adjoining muscles. Another observation of Haller mentioned by Dr. Alison, 
that of " blood escaping from vessels between the layers of a living membrane, and never- 
theless pursuing its course in a regular stream for a time, even against the influence of gra- 
vity," may be fairly referred to the vis a tergo from the open vessel. In the fluids of such a 
nicely adjusted hydraulic apparatus as the vascular system of animals, and even vegetables, 
it is surprising how readily motions may be produced by various physical causes : and when 
these motions are magnified by the microscope, it is not wonderful that they should have 
been mistaken for vital movements of the fluids themselves. 



204 



PROXIMATE ELEMENTS OF DISEASE. 



413. We have before stated (§ 408) that inflammation may originate 
either in determination of blood, or in congestion ; and we now proceed 
to show that inflammation essentially comprises both these morbid ele- 
ments. The mode in which the process of inflammation has been chiefly 
studied, is by observing under the microscope the effect of irritants on 
the frog's web. It must be remembered, however, that this is only one 
mode in which inflammation may begin, and we shall afterwards find 
that cold-blooded animals fail to show some of the most remarkable re- 
sults of inflammation. 

The effect of weak irritants on the vessels of the frog's web has been 
described before (§§ 294, 326). We then found that irritation may cause 
first determination of blood, then congestion ; these results being depend- 
ent on an enlargement respectively of the arteries and of the veins and 
capillaries. But if a strong irritant (as a grain of capsicum, or a minute 
globule of essential oil*) be applied to the web of a frog, all the blood- 
vessels speedily become enlarged ; those most irritated are very large 
and red, and the blood in them is stagnant and coagulated: contiguous 
vessels are also very large, but less red, and the motion of the blood in 
them is slow, and often in pulses or oscillations ; whilst in vessels be- 
yond, the enlargement of the capillaries is less considerable, but that of 
the arteries is obvious, and the current of blood is very rapid. 

Now, it is obviously the stagnation or tardy motion of the blood in the 
most enlarged capillaries, in the midst of surrounding increased flow, 
that most characterizes inflammation ; and we have still to inquire what 
is the cause of the stagnation. This cause must be either in the vessels, 
or in their blood, or in both. The latter we shall find to be the true 
case. 

414. We have already pointed out (§ 300) that atony and flaccidity 
of blood-vessels may become a cause of impediment to a current through 
them, not by preventing these vessels from actively contracting on their 
contents, (for they have no such power), but by removing that tone by 
which the vessels maintain the calibre and the tension best calculated to 
transmit onwards the force of the current. Vessels thus weak and in- 
elastic, instead of equably conveying the current, become distended, 
lengthened, and tortuous in receiving it; and by their very mass, as 
well by their inelasticity, they partly break the force of the current, and 
partly turn it into other channels. The mode in which this results in 
inflammation will be better understood, if we review other local modifi- 
cations of the circulation in comparison with it. 

In determination of blood, the arteries are enlarged, and so are the 
capillaries in due proportion ; the circulation is therefore equally increased. 
In congestion, the capillaries are enlarged, without any increase of the 
arteries: the motion is therefore impaired ; but still, being gentle, it may 
diffuse itself through the mass, which moves slowly. But if to con- 
gested capillaries there be added the increased and abrupt force of the 
current from enlarged arteries, or if to determination of blood (enlarged 
arteries) (§ 326) an atonic congestion of the capillaries be joined, the 
propulsive power of the current will be impaired. As in the experiment 

* These are preferred because they produce no chemical change in the parts. 



INFLAMMATION — NATURE AND PHENOMENA. 



205 



with the intestine (§ 300), the blood will pulsate or oscillate in the dis- 
tended vessels rather than pass through them; and the main current will 
pass through collateral anastomosing channels, which become the seat 
of simple determination or increased flow. This is just the state of 
things in the incipient stage of inflammation ; and if either the capilla- 
ries do not speedily recover their tone, or the arteries do not contract, 
the blood in parts become stagnant, its particles adhere to each other, 
and to the walls of the vessel, and the obstruction is confirmed. The 
arterial portions of some of the obstructed capillaries are still open, and 
exposed to pulsative force from the supplying arteries, which continues 
to strain their coats, and cause an oscillatory motion of their blood par- 
ticles, but no passage through them. Such are the phenomena which 
we see under the microscope. 

It may, then, be fairly inferred, that one cause of the stagnation or 
retardation of the blood in an inflamed part, is a weak, inelastic state 
of the capillary vessels ;* such, in fact, as exists in cases of atonic con- 
gestion; and on referring to the causes of inflammation (§ 404), it mav 
be perceived that many of them act by first producing congestion. Nay, 
w r e have found (§ 294) that even irritants, in some measure, operate in 
the same way. " The continued application of stimuli to a part is some- 
times followed not by inflammation, but by congestion. This especially 
happens in the liver, a chiefly venous organ; but it occurs also in other 
parts. It might be supposed that the stimuli act by exhausting the 
contractility of the small vessels, and thus leaving them weakened and 

distended by their contents 

But on the application of a strong stimulant, such as a minute particle 
of essential oil, the previous arterial contraction is not apparent, and the 
enlargement is speedy and obvious, causing extreme rapidity of motion 
and enlargement in all the vessels. In a few minutes, the size of the 
arteries begins to diminish, and with it the motion in the capillaries be- 
yond them. Many of the capillaries still retain their enlarged dimen- 
sions; in them the motion is most sluggish, and, in some parts, ceases 
altogether."! 

415. But it is very certain that the obstruction, and much of the other 
features of inflammation, are generally dependent on changes which 
take place in the blood within the inflamed vessels. J. Hunter did not 
overlook this; and, besides describing the coagulation of the blood in the 
most inflamed vessels, he mentions the adhesion of fibrin to their interior. 
The coagulation of the blood in the inflamed vessels, was also noticed 
by Gendrin and others; and Dr. Marshall Hall attributed the obstruction 
of the vessels in inflammation, to the adhesion of blood-globules to the 

* It may, perhaps, be objected, that I have supposed a similar atonic state of the arteries 
to be the cause of an increased flow through them, and to be the physical cause of determi- 
nation of blood. But this is no objection. The arteries, as compared with the capillaries, 
are few in number; their current is rapid ; they are exposed to the pressure of a vis a tergo, 
which maintains the velocity of their current, whatsoever may be their calibre: when their 
coats lose some of their tone, this pressure of blood into them, stretches them to tension, and 
they thus admit an augmented force and volume. In capillaries, on the other hand, the cur- 
rent is so much subdivided and straitened, that it is easily disturbed, and the motion, natu- 
rally tardy, is readily arrested. 

t Extracted from the Author's Gulstonian Lectures for 1841; Med. Gaz., July 16. 1S41. 



206 



PROXIMATE ELEMENTS OF DISEASE. 



walls of the vessels. It appeared to me, that microscopic observation 
ought to be directed to this point more specially than had hitherto been 
done ; and in 1841, I made many careful examinations of the early 
stage of inflammation in the frog's web. Some of the results were pub- 
lished in the Medical Gazette of July of that year; and as they have 
been confirmed by several other observers, it may be proper to describe 
them. 

Poiseuille, in his observations with regard to the motionless layer of 
serum which intervenes between the moving blood and the walls of blood- 
vessels, had noticed that the blood particles sometimes get into this still 
layer, and either remain fixed there, or move onwards more slowly than 
the rest of the blood. In repeating this observation, Mr. Toynbee and 
myself remarked, that it was not the red particle, or elliptical blood discs, 
that thus adhered to, or slowly rolled along the sides of the vessels, but 
the white or colorless globules (§ 212), called by Muller, lymph globules. 
(The following description is taken from my Gulstonian Lectures, of 
1841): — "I have never seen a solitary elliptical disc adhering to the 
fides of a vessel ; and whenever one was arrested in its course, it was 
from its becoming hitched by one or more of the adherent round globules. 
But what appeared to me most remarkable with regard to these white 
globules, was the great difference in their number under different circum- 
stances. In young frogs, and in those much subjected to experiment, 
they are always present in great numbers ; but in healthy adult frogs, 
placed under the microscope with as little handling of the w T eb as possi- 
ble, there were comparatively few to be seen. I have watched, for ten 
minutes at a time, without seeing one: the motionless layer was very 
thin, but clear, and all the blood particles in the larger vessels seemed 
to move at the same rate of speed." It is under these circumstances 
that the effect of irritation or mechanical injury was best seen. "By 
pressure of the finger on the web, partial stagnation was produced in 
many of the vessels; and when this yielded to the returning current, the 
walls of the vessels were seen studded with the white globules; whilst 
many others of the same kind rolled over them slowly in the direction 
of the current. I have before mentioned (§ 294), that a similar result 
ensued, after the web had been stimulated by capsicum or an aromatic 
water. Even in the rapid flow of blood following these applications, 
minute globules could be seen creeping slowly along the transparent out-- 
line of the larger vessels ; and as the arteries contracted, and the flow 
through the other vessels became less rapid, the number of these glo- 
bules increased, their motion became slower, and many adhered to the 
sides of the vessels. If the stimulus used was rather strong or long 
applied, the number of sticking globules w 7 as so great as to prevent the 
red particles from passing; and these becoming impacted in increased 
numbers, gave to the obstructed vessels a uniform and deeper red color. 
When the stimulation was moderate, and equalty applied to the w T eb, 
the stagnation usually took place first in some of those anastomosing 
veins, in which the current is naturally slow, and varying in direction; 
but when a stronger stimulus (as an essential oil) was used, the stagna- 
tion speedily ensued at the point of its application; in fact, unless very 



INFLAMMATION NATURE AND PHENOMENA. 



207 



minute quantities were employed, the stagnation was almost immediate 
and extensive."* 

416. I have varied these observations in a great many ways, and have 
always found considerable or continued irritation of the vessels in the 
frog's web to be attended with the appearance and adhesion of the color- 
less globules ; and that when the irritant is at all strong, or frequently 
applied, many vessels become totally obstructed, appear larger and red- 
der in consequence of the accumulation of red particles in them, (the 
blood liquor having passed on,) and exhibit to the naked eye all the ap- 
pearance of inflammatory injection. The chief cause of obstruction 
seems to be comprised in the two circumstances — the increased produc- 
tion of the white globules, and their remarkable disposition to adhere to 
the walls of the vessels and to one another ; each of these circumstances 
must now be noticed. 

The origin of the white or lymph corpuscles (§ 195), seen in the blood, 
is involved in some doubt. They are distinctly spheroidal bodies, of a 
gelatinous consistence, and composed of granules, some of which have 
the appearance of nuclei. According to Mr. Addison, f they are in- 
vested by a delicate membrane, constituting a compound granular cell, 
which slowly by the action of water, more promptly by the operation of 
solution of potass, bursts and discharges granules and molecules. In this 
respect, they differ from the blood-discs, which are speedily burst, and are 
almost dissolved by either of these fluids. They appear to consist of fibrin, 
or rather deutoxide of protein; and as in the case of other granular 
bodies formed in an albuminous fluid, each granule probably has a central 

* Med. Gaz., July 23, 1841. It was not until after these observations were made that 
I became acquainted with similar ones, previously published by Mr. Addison, of Great Mal- 
vern, in the Med. Gaz. of Jan. 29th of the same year. The following description is given 
by Mr. Addison, — "In the frog's web, two days after the application of salt, in some of the 
larger capillaries or smaller veins, there are a great number of globules, No. 3," (lymph glo> 
bules;) "and it is quite extraordinary to observe the difference in movement between these 
round speckled globules and the oval ones; the blood globules pass in a continued stream, 
while in the same fluid, in the same vessel, are a great multitude of other (lymph, No. 3) 
globules, which do not move, or do so very sluggishly: every now and then they move 
slowly, apparently urged on by the repeated knocks they receive from the blood globules. 
It would appear, that after the capillary vessels have been acted on by the salt, that the 
round (lymph) globules accumulate in an unusual manner, and the blood globules repeatedly 
slide over and knock against them. In some of the vessels, there is a rapid stream of blood 
in the centre, whilst at the circumference there are many stationary, round, spotted globules, 
which do not obey the impulse which urges the stream of blood, but remain, or move on 
slowly by little starts, at uncertain intervals, and with unequal pace." This account cor- 
responds very exactly with what I have myself observed; but I should not consider the ex- 
periment so conclusive with regard to inflammation, inasmuch as the chemical action of the 
salt might have been concerned in the production of the lymph globules, as salt seems to 
generate granules in the blood liquor. In my observations, I was careful to use no irritant 
which has any known chemical action on the blood. " The greater prevalence of lymph 
globules in the motionless layer, had been noticed by Wagner and others ; and their more 
abundant production in an inflamed part has been mentioned by Mr. Gulliver. The pre- 
sence of the pale corpuscles in inflamed vessels, has been questioned by Dr. Hughes Ben- 
nett, who hints that Mr. Addison and myself may have mistaken for them epithelium cells 
lining the vessels: but the plain description above given, and which I have repeatedly 
verified, admits of no such interpretation. The granular corpuscles may be distinctly seen 
to roll sluggishly and with a dragtail before they stop; which they obviously do by adhesion 
to the interior of the vessel. I cannot understand why Dr. Bennett has failed to see so clear 
an appearance. 

| Trans, of Provincial Med. and Surg. Assoc., 1843. p. 240. 



208 



PROXIMATE ELEMENTS OF DISEASE. 



nucleus or molecule of fat, which makes their specific gravity lower than 
that of the red particles : hence their disposition to collect in the buffy 
coat of inflamed blood. The increased number of these bodies within 
the vessels of an inflamed part, has been observed by Mr. Addison as 
well as by myself; and from careful comparison with those in uninflamed 
vessels, I infer that this increase is due not merely to their being arrested 
in their transit through the inflamed vessels, but to their being actually 
formed in greater numbers.* Nor is it difficult to explain their produc- 
tion, if we consider the combination of causes which are operating in in- 
flamed vessels. The blood liquid is highly charged with protein, which 
needs only a further process of oxidation to assume the solid form of the 
deutoxide : this process is supplied by the free current of arterial blood 
(determination) which rushes into the obstructed portions, and brings the 
red particles, the oxygen carriers, in such forcible contact with blood 
liquor as favors the transfer of oxygen to the protein contained in it. As 
the protein becomes oxidized, it consolidates in a granular form, and the 
more readily around the oily molecules always diffused through the blood 
liquid ; and these form the nucleoli visible in the larger granules. But 
the granules also cohere in clusters, and form the pale corpuscles of va- 
rious sizes which appear adhering to and creeping along the sides of 
irritated vessels. f This explanation corresponds with the sudden manner 
in which they appear in such numbers in the vessels of the frog's web, 
not only after continued irritation, but after momentary rough handling 
or squeezing the web, which partially obstructs the vessels, and directs 
the force of the arterial current on their contents ; the walls then appear 
studded with adherent and creeping corpuscles; but as the impediment 
and the determination are not here permanent, these corpuscles are soon 
swept away and disappear. In inflamed vessels, on the other hand, they 
are a constant element, and as we shall find, are chiefly instrumental in 
producing its phenomena and results. Their abundance in inflamed 
blood has been noticed by Gendrin, Gulliver, Addison, and others. 

417. We have next to notice the peculiar disposition of the pale cor- 
puscles to adhere to the w T alls of the vessels. This disposition has been 
ascribed to a vital attraction; but although it is made subservient to the 
purposes of life and organization, it appears to me to be the mere result 
of the physical property of adhesiveness common to soft solids of glutinous 
material. The same property is shown in the field of the microscope in 
the manner in which the pale corpuscles stick to the glass, whilst the 
red particles float in the liquid. It has, however, been objected, that in 

* This statement, which corresponds with that given previously (§ 415), has been made 
the subject of animadversion and inconsiderate ridicule by parties who find it easier to cri- 
ticise observations which oppose their own notions, than to investigate the matter carefully 
themselves. It will be perceived that the pathology of the blood in inflammation indubita- 
bly proves that the pale corpuscles are increased not in a part only, but in the whole blood ; 
whereas if they were only accumulated in the inflamed part, there would be fewer than 
usual in the blood at large. In the former edition I stated the fact; the advance of animal 
chemistry enables me now to offer its explanation. 

f The accompanying diagram exhibits the appearance of a small portion of the capilla- 
ries of a frog's web after the application of a grain of capsicum. The elliptical blood-discs 
(b) are running in the axis of the vessel, which is much narrowed by white globules adher- 
ing to the walls, or only slowly rolling along them. These globules are speckled with nu- 
clei or granules, refract the light strongly, and when rolled on by the current, some of them 



INFLAMMATION — NATURE AND PHENOMENA. 



209 



blood drawn " the white corpuscles do not show any tendency to adhere 
to each other or to the red particles, which they naturally would do if 
their surfaces were adhesive enough to cause them to stick to the walls 
of the vessels."* But this objection has no force when it is considered 
that the white corpuscles do cohere most readily when brought into con- 
tact, and the reason why they appear separate in the field of the micro- 
scope, is because they at once stick to the glass and are not free to move 
and congregate like the red particles. They do not usually adhere to 
the red particles because they are smooth, loose sacs of fluid, the exos- 
motic properties of which are intended to keep them as loose and free 
as possible, so that they are carried with every motion of the current. f 
But there are circumstances in which the red and pale corpuscles do 
cohere together; and that is when their compression within the vessels 
prevents exosmosis; so also there is a condition of the walls of the blood- 
become pear-shaped from their sticking to the vessel, thus forming a kind of dragging tail, 
seen very well in those marked (a); on altering the focus, similar globules may be seen ad- 
hering to the other parts of the vessel. The shaded portion (c) is totally obstructed with 
white and red particles, so impacted together as to form a homogeneous red mass. In such 
a case I have often seen the particles at (c?) exhibit a pulsating or oscillatory motion, (cor- 
responding with the action of the heart;) and this, after a time, succeeds in breaking down 
the obstructing mass, which passes away in clots, leaving the vessel (c) studded with pale 
corpuscles like the other, and this result is observed whether the obstruction has taken place 
suddenly, or slowly, showing that in either case these corpuscles are present. 




* British and Foreign Medical Review, July, 1844, p. 107. 

t These physical diflerences may be rudely illustrated by a clot of adhesive jelly and a 
thin bladder containing water 5 the jelly adheres to any plane or concave surface, so that it 
may not be detached by inversion; the bladder rolls readily when the surface is inclined, and 
will not adhere even to the jelly. 

14 



210 



PROXIMATE ELEMENTS OF DISEASE. 



vessels in which the pale corpuscles adhere little or not at all to them; 
and that is when endosmosis through their walls is as free as exosmosis, 
in the absence of all distention of the vessel ; and this explains why, in 
the instance before mentioned, the pale corpuscles which adhered, be- 
come detached as the circulation is restored to its natural state. 

The ordinary pale corpuscles of the blood certainly have an investing 
cell wall, as first shown by Mr. Addison; but those recently formed in 
inflamed vessels do not appear to me to be so invested, and hence their 
more adhesive property. But they soon acquire this covering, which 
seems to be nothing more than an outer coating of coagulated albumen 
or deutoxide of protein more solid than the rest of the corpuscle. In 
like manner, globules of milk, oil, &c, acquire in serum an albuminous 
coating, as observed by Ascherson, Donne, and Gulliver. I am aware 
that the expression of this opinion will not be favorably received by those 
who uphold the doctrine of cell-life as fundamental to all processes of 
organization; but we have already noticed facts in regard to the organ- 
ization of fibrin (§§ 211, 212) which show that this doctrine is by no 
means of universal application. 

418. Except as the chief vehicles of oxygen, the red particles are less 
concerned than the white corpuscles, in the commencement of the ob- 
struction of inflamed vessels: they are seen still free, although twisting 
and struggling between the accumulating white corpuscles: and so long 
as they so pass, they show no disposition to cohere or form rouleaux: 
but if the obstruction increase a little by another white corpuscle or two 
more, so narrowing the path, that the red particles can no longer pass, 
then these also stick, and forced by the current from behind, their flexible 
and elastic bodies become jammed in such numbers in the interstices of 
the white corpuscles, that the whole vessel speedily presents an almost 
homogeneous deep red color, and contains a great accumulation of red 
particles, the liquor sanguinis having filtered through. This is the period 
of total obstruction, the process of which may be watched when the irri- 
tation is extremely gentle; but in most instances it is produced so sud- 
denly and extensively that the successive changes escape observation, 
and the contents of the vessels at once appear stagnant and uniformly red, 
as if the blood had suddenly coagulated within them. These appearances 
are illustrated in the diagram (p. 262), and serve to explain the vascular 
redness of an inflamed part, and, as we shall see, will aid us in under- 
standing the further results of the inflammatory process. 

It seems, then, to be well established, that an essential part of inflam- 
mation is the production of numerous white globules in the inflamed 
vessels ; and that the obstruction of these vessels is mainly due to the 
adhesive properties of these globules. The production of these globules 
must then be considered as a constant fact in the history of inflammation 
and nutrition ; but it may be observed, that sometimes it seems to be 
the direct effect of an irritant acting on the blood-vessels and their con- 
tents (§ 415); in other instances, rather to result from determination of 
blood into previously congested capillaries (§ 414). Any circumstances 
causing continued determination of blood, where congestion is already 
present, will occasion the production of the white globules, and, conse- 
quently, inflammatory obstruction may ensue. The complete obstruc- 



INFLAMMATION — NATURE AND PHENOMENA. 



211 



tion of some capillaries by the confused conglomeration of the corpuscles 
takes place in all cases of severe inflammation of the frog's web ; but 
there are slighter kinds of increased vascularity, in which there is no 
total obstruction, but a continued enlargement of the capillaries and veins, 
as well as of the arteries. This might be called simple determination 
of blood; but it differs from that of a transient character, in the motion 
in the capillaries and veins being slower, and in the vast number of 
white globules seen moving slowly in them(§ 294). Very probably this 
kind of process takes place in the lowest forms of inflammation. Some- 
thing of the kind is generally seen in the capillary circulation of young 
frogs. 

419. The foregoing experiments and considerations lead to the con- 
clusion, that the most essential character of inflammation consists in an 
increased motion or determination of blood to the affected part, with a 
more or less obstructed flow through the part: the force of the increased 
motion being partly expended in the arterial portion of the dilated 
capillaries (§ 414), and partly diverted into the collateral channels so 
abundantly supplied by the anastomosis of vessels (§ 410). The obstruc- 
tion in the vessels of an inflamed part we have found reason to ascribe 
in part to the increased mass in the smaller vessels, and to the dimin- 
ished elasticity of their coats; and in part, to the unusual formation of 
white corpuscles, which adhere to the walls of the tubes, and to each 
other. Of the exciting causes of inflammation, the direct irritants 
(§ 402) seem to produce obstruction in both these modes; those which 
act indirectly (§ 403), on the other hand, in the first instance produce 
congestion — to which determination of blood being subsequently added, 
the inflammatory process begins : hence the latter causes, although very 
common, are not so sure of exciting inflammation as direct irritants are. 

420. The effect of these changes, essential to inflammation, is, to ex- 
pend much of the circulating force conveyed by the arteries on their 
capillary terminations; and the enlargement and tortuosity of these capil- 
laries, the production of globules which adhere to their sides, and their 
total obstruction by the same means, seem to be so many progressive 
expedients used by nature to direct the force of the circulation to that 
part of the vessels by which the process of reparation and nutrition is 
chiefly carried on. We have further suggested, that an obvious effect of 
this local direction or determination of force, is to supply oxygen more 
freely to the plasma, and the resulting formation of a solid deutoxide of 
protein is the obvious explanation of the formation and increase of those 
white corpuscles which augment and complete the obstruction. This 
leads us to consider the further changes effected by inflammation. 

421. We have already found that an inflamed part is the seat of deter- 
mination and of congestion or obstruction. It is this combination which 
leads to the changes which characterize inflammation, and which, in ex- 
tent and variety, exceed the changes from any other kind of hypereemia. 
The determination of blood to and near the obstructed vessels is attended 
with the usual results of determination (§ 333, &c); but to a greater 
extent than usual, because the cause of determination is more permanent. 
The congestion or stagnation has also its effects (§ 303, &c); but more 
marked and peculiar than usual, because the obstruction is more com- 



212 



PROXIMATE ELEMENTS OF DISEASE. 



plete than in congestion in general, and because it is modified by the 
influence of a continued force of blood acting physically and chemically 
against it. All these circumstances point out that the natural functions 
of the vessels must be much modified by inflammation, and this in dif- 
ferent modes in different parts of the inflamed site. Thus, in the vessels 
which are the channels of an increased flow, the functions will be more 
or less exalted or excited; whilst in those that are obstructed, vital pro- 
perties will be more or less impaired. It is the approximation of two 
such opposite conditions, excitement and interruption of living actions 
almost in the same spot, that renders continued inflammation so seriously 
destructive to structure as well as to function. 

422. Inflammation at first much exalts sensibility (§ 133) and con- 
tractility (§ 111); causing tenderness, pain, and spasm. But the ob- 
structed circulation may cause a suspension of these properties (§ 273) 
in the centre of the mischief, whilst in surrounding parts, the seat of de- 
termination, they are exalted. The sympathetic relations (§§ 152, 156) 
of the inflamed part are also commonly increased. Natural secretions 
are either suspended by inflammation, or modified by the addition of 
various modifications of the serous and albuminous parts of the blood. 
This involves the change of nutritive secretion, w T hich is so important 
and early a part of inflammation, that it must be noticed more fully. 
We shall recur to the other effects of inflammation under the head of 
symptoms. 

423. The effusions from inflamed vessels at an early period are much 
the same as those from tense congestion (§ 305-8) and determination of 
blood (§§ 340, 1); but they commonly occur in greater abundance, con- 
tain more animal matter, and, as the inflammation advances, they some- 
times present appearances not found in the products of mere congestion, 
or determination. Thus the effusion at first is a thin serum, causing 
swelling in complex textures, accumulating in the dependent parts of 
serous cavities, or diluting the secretion of the more simple mucous 
membranes. But soon fibrin is also effused, part of wdiich may concrete 
into coagulable lymph, or still remain dissolved, as in the liquor san- 
guinis. Thus an inflamed pleura becomes coated with a film of lymph; 
and the clear fluid effused into the sac, when removed from the body, 
sometimes spontaneously separates into a fibrinous clot and serum. This 
occurring in complex textures gives a hardness to their swelling, as in 
phlegmon of cellular membrane, hepatization of the lung, &c. In mu- 
cous membranes, there maybe thickening of the submucous texture, and 
the mucous secretion becomes unusually viscid. 

424. The microscope has supplied much detailed and precise infor- 
mation on the nature of inflammatory effusions, although there is yet 
room for further research on their varieties and relations to each other. 
In the frog's web, after inflammation has continued some hours, there 
appear outside of the vessels (especially of those in which the strongest 
current encounters the most complete obstruction) white globules or 
corpuscles, with specks in them, exactly like the pale granular glo- 
bules within the vessels (§ 415). These are also found in various in- 
flammatory effusions, and are called exudation corpuscles, granule cells, 
or fibrinous globules. Mandl supposes them to be merely consolidated 



INFLAMMATION — NATURE AND PHENOMENA. 



213 



globules of fibrin, and states, that the liquor sanguinis may be seen to 
coagulate in similar globules on the glass of the microscope. But these 
latter have been shown by Gerber to be mere albuminous granules, 
without regularity of form, and quite unlike the true exudation corpuscle, 
which also consists of granules, but has a defined outline, and in many 
instances an investing cell, whence the term granule cell (Vogel). In 
addition to these bodies, the fibrin effused by an inflamed membrane also 
contains a mesh of extremely fine fibres, first noticed by Messrs. Gulli- 
ver* and Addison. f Both these observers describe the nucleated or gra- 
nulated corpuscles as occurring among these fibres, together with more 
minute granules and molecules, which appear to be similar to those 
which compose the corpuscles. Lastly, some portions of solid effusion 
present no distinct structure, but are either irregularly granular like co- 
agulated albumen, or completely amorphous and homogeneous (Vogel), 
hyaline (Gerber). Now, some or all of these solids appear in inflamma- 
tory effusions, although they occur in very various proportions, and pre- 
sent different modifications, to be noticed hereafter. The following is a 
summary of. these elementary solids of inflammatory effusions. 

1. Molecules, immeasurable from minuteness, each appearing as merely 
a dark speck. Probably composed of a fatty matter (Davy, Gulliver). 
[Smaller primitive molecules ; Gruby.) 

2. Granules, (Gerber, Addison,) measuring from T oJ M to g-^oo °f an 
inch, appearing as a light spot, surrounded by a dark circle. Probably 
consisting of deutoxide of protein, with a central molecule of fat. 
[Larger primitive molecules, Gruby.) 

3. Fibrils, extremely fine, interlaced and decussating, the same with 
those seen in the buffy coat of the blood (§ 194). 

4. Lymph or exudation corpuscles, compound granules, granular cells, 
measuring from g o*o o *° t4o °f an ^ ncn (Gulliver), composed of granules 
and molecules, and sometimes enveloped in a cell. 

5. Pus globules appear to be enlarged modifications of the last; but 
more distinctly cells, containing liquid with more or fewer granules, 
some of which are of larger size than the rest, and forming nuclei. Be- 
sides the solid deutoxide of protein, which constitutes these solid parts, 
they contain a dissolved form of protein, the tritoxide. 

6. Irregular granular and hyaline matter; the former of albuminous 
composition, with more or less fat: the latter also albuminous, with more 
or less gelatine. These constitute the materials of tuberculous and 
other aplastic or cacoplastic deposits (§ 212). They often exhibit traces 
of cells and fibres, but appear degenerated or imperfectly formed. 

In addition to the above, inflammatory effusions usually contain the 
usual solids generated by the part, such as mucous globules, epithelium 
scales, epidermis, and also blood corpuscles. 

425. Of these elementary solids, the fibrils certainly may form from 
the effused liquor sanguinis out of the vessels, and even removed from 
the body (Addison); but, it is a question whether the others concrete 
spontaneously from the liquid fibrin, or grow from germs, (molecules or 
granules,) disseminated from the vessels, or adjoining textures. The 



Note to Gerber's General Anatomy, p. 31. 



f Med. Gaz. 3 April 15, 1841. 



214 



PROXIMATE ELEMENTS OF DISEASE. 



close resemblance of the exudation corpuscles and their contents, to the 
white globules and granules, so abundantly produced in the blood of the 
inflamed vessels, would seem to indicate their identity; but it is not easy 
to understand how they pass through the walls of the vessels, in which 
no pores are visible under the highest magnifying powers. Mr. Addi- 
son has, indeed, represented the white globules as first passing into the 
substance of the wall of the blood-vessel, and then beyond it; but this 
would seem too slow a process. It would appear more probable either 
that nuclei or molecules, too small to be discernible, do pass out in this 
way, and then grow and propagate compound granules (granular and 
pus corpuscles); or, that these corpuscles are formed by coagulation in 
the effused liquor sanguinis as the fibres of fibrin certainly are. 

426. These solid products of inflammation are the materials of which 
new membranes, textures, and deposits are formed; and present every 
variety of plasticity, or capacity of organization, from that of perfect 
cicatrices and false membranes, down to that of yellow tuberculous mat- 
ter.* As we shall have to notice these further under the head of results 
of inflammation, we shall now review inflammation in relation to its fur- 
ther consequences and symptoms. 

427. Inflammation is always attended with more or less effusion. 
Where the inflammation is slight, this effusion may remove it by unload- 
ing the engorged blood-vessels; but where the inflammation is more 
intense, that is, where the obstruction is considerable, and the determi- 
nation of blood strong, the effusion may go on to a great extent without 
resolving the inflammation. It is then that the more serious effects of 
inflammation result. The effused matters press on, and pervade the ad- 
joining textures, derange their nutrition, and impair their cohesion ; and 
thus takes place the softening of textures, which occurs chiefly in those 
of a complex kind, which retain the effused matter. The continued 
obstruction in the inflamed part, leaves the veins and lymphatics free to 
absorb, and the high pressure and determination of blood tend rather to 
promote this process of absorption. Hence, as new matters are effused, 
the old texture is compressed, disintegrated, and absorbed; the finer 
exudation corpuscles and fibres themselves are removed or altered, and 
the large pus globules alone remain: this is suppuration. Or, if the 
original obstruction of the inflamed vessels be extensive, or have been 
rendered so by the subsequent effusion, the supply of blood may be so 
stopped in a part, that it dies, and the dead part may then either be only 
dissolved and absorbed at its circumference, and separated from the liv- 
ing textures in form of a slough; or, if more extensive, the dead part 
may pass into decomposition before it can be separated; thus occur 
gangrene and sphacelus. If the inflammation be of a lower kind, the 
obstruction less complete, and the effusion more gradual, the nutrition 

* This statement, which is founded on the recent microscopic observations of Gerber, 
Gulliver, Addison, Watt, and others, is a remarkable confirmation of views on the nature of 
pus and tubercle, which I have entertained for the last twenty years, and to which I ad- 
verted in the following sentence, published nineteen years since: — "I am myself disposed 
to consider tubercular matter, pus, and coagulable lymph, only as varieties of the same 
albuminous matter that exists in the blood, and differing from each other rather in mecha- 
nical condition, and consequent capability of organization, than in chemical composition." — 
Rational Expos, of Physical Signs of the Diseases of the Lungs and Pleura, 1828, p. 159. 



INFLAMMATION SYMPTOMS AND EFFECTS. 



215 



of the natural texture is only impaired, not arrested, and from the in- 
creased deposition of solid matter, induration or consolidation takes 
place. 

SYMPTOMS AND EFFECTS OF INFLAMMATION. 

428. We have described the process of inflammation in its intimate 
nature and phenomena; we have now to notice its more obvious effects 
on function and structure, which become symptoms of its existence. 
These symptoms may be divided into local and general ; the local occur- 
ring chiefly in the part which is the seat of inflammation; the general 
affecting the system at large. 

LOCAL SYMPTOMS. 

429. We have before stated that the local symptoms are commonly 
more marked, and earlier in order of occurrence when inflammation is 
excited by local irritation (§ 402) ; the fever which afterwards supervenes 
may even disguise the local symptoms. The chief local symptoms have 
been already mentioned in the definition, redness, heat, pain, and swell- 
ing, to which may be added various disturbances of the function of the 
part affected. We shall explain and illustrate these symptoms. 

430. The redness of an inflamed part is obviously due to the increased 
quantity of blood in the vessels. All these vessels are much enlarged, 
so that they receive many more red particles than usual ; and the finest 
capillaries, which commonly are invisible from their admitting only the 
liquor sanguinis with now and then a red particle, are now distinctly 
colored from the number that pass into them. Some observers have 
thought that new vessels are formed by the blood forcing its way through 
the textures. I have never seen this in the frog's web ; but it appears 
to take place in some textures which are not naturally vascular, such as 
the anterior part of the cornea, and cellular cartilage (Toynbee). But 
the microscope show r s that besides the augmented size of the blood-ves- 
sels which convey blood, much of the redness of inflammation arises 
from the vessels in w r hich the blood is stagnant. The color of these is 
much more red than that of the vessels simply congested, or through 
which a current still passes; and this has before been referred to an ac- 
cumulation of the red particles, which takes place in them(§§ 415, 417, 
note). These vessels appear so impacted to their outmost limits with 
coloring matter, that the shape of the blood-discs and of the white cor- 
puscles is no longer discernible: yet these are still present; for when an 
obstructed vessel re-opens, the red mass breaks up into clots and parti- 
cles, and many white corpuscles are left sticking to its walls. (See. note, 
p. 213.) It is obvious, therefore, that the obstructed vessels become 
stuffed, as it were, with red as well as white corpuscles, which cause a 
brighter and stronger red than that of congestion. In many instances, too ? 
it may be seen that the redness of an inflamed part is augmented by spots 
and patches of extravasated blood, which prevail especially in some 
varieties of inflammation. 

The redness of inflammation presents great varieties according to the 



216 



PROXIMATE ELEMENTS OF DISEASE. 



number and distribution of the capillary vessels of the part; but its 
most essential seat being in the capillaries, its most constant character is 
a diffused or capilliform redness. This is commonly far more vivid and 
general in the living than in the dead body. In the skin and mucous 
membranes during life, it is often seen as a uniform blush of color, vary- 
ing from a delicate pink to a bright crimson. After death this blush has 
sometimes entirely disappeared ; but commonly more or less of it remains ; 
and on examination with a lens, it is found to consist chiefly of numerous 
vesicular striae, network, or points, with here and there larger vessels 
and ramifications also injected. But the large vessels (veins) are dis- 
tended much less generally than in congestion (§ 280), and the redness 
is therefore less arborescent and ramiform. To explain the reason of the 
disappearance of inflammatory redness after death, we must bear in mind 
that much of it depends on determination of blood (§ 326) which is 
maintained by the action of the heart, distributed by the arteries; and 
that when this ceases in death, the tonic contraction of the arteries, which 
survives for a few hours, expels the blood from the vessels (§ 120). A 
similar effect is sometimes produced during life, by cardiac syncope. 
The redness that remains after death seems chiefly to consist of the ves- 
sels which have become totally obstructed and impacted with blood, or 
have been long congested and have lost their tone (§ 295). This furnishes 
us with a useful means of distinguishing in different cases the comparative 
prevalence of the elements of inflammation. Thus in cases in which the 
redness disappears after death, we may know that the predominant element 
was local determination of blood (§ 409) without much obstruction or per- 
manent congestion. This is observed in erythematic and diffused mem- 
branous inflammations, the cutaneous inflammations of eruptive fevers, 
and the early stages of all inflammations excited by moderate local irri- 
tation (§§ 402, 415). On the other hand, if much redness remains after 
death, we may infer that obstruction or congestion of the vessels has 
existed to a great extent. This happens especially in phlegmonous in- 
flammations, those of parenchymata, and others which have advanced 
to a certain intensity, and those which have originated in congestion 

The florid hue of the redness is also during life a sign of the predomi- 
nance of determination, for it shows that the blood is chiefly arterial and 
not stagnant. Where congestion prevails, or where the blood has been 
long, stagnant in many vessels, the color is deeper : but it is rarely so 
deep as in pure congestion, for the presence of whue globules tends to 
lighten it or give it a florid tinge, and it is probable that the red particles 
stagnant in the vessels retain their power of receiving oxygen from the 
communicating arteries, which are the channels of determination of blood. 
In the dead body these distinctions are not equally available, for the 
arterial part of the blood may have been removed by the contraction of 
the vessels, or darkened by stagnation; and the livid portions speedily 
become florid on exposure to the air.* 

* I have often in the dead-house seen mere congestive redness mistaken for inflammatory, 
because it was florid, from the action of the air, or from the translucence of a subjacent 
white structure. Frequently, too, the claret stain of arteries and intestines is mistaken for 
inflammatory redness ; a common lens will prove it to be not so, by showing that it is not 
vascular. 



INFLAMMATION SYMPTOMS. 



217 



The progress of inflammation modifies the redness. The color be- 
comes more florid and deeper as the inflammation advances to its acme; 
it then becomes either livid before it subsides, or paler from the color of 
the effusion. In complex textures, the effused lymph or pus changes 
the redness to pink, flesh color, drab or yellow. 

431. The heat of inflammation is obviously dependent on the increased 
flow of blood to and through the part ; and it may be considered the re- 
presentative of the amount of determination of blood concerned in the 
inflammation. Hence it is high in extensive and active inflammation, 
and is generally proportioned to the florid redness or arterial vascularity. 
It is not certain whether the high temperature of an inflamed part is 
caused by the augmented changes going on in that part, or whether it 
arises merely from the greater quantity of warm blood which passes 
through it. John Hunter made some observations to determine this 
point, and never found that the temperature of an inflamed part was 
raised above that of the interior of the body, which it might be expected 
to be, if inflammation w T as in itself a calorific process. That extensive 
inflammation raises the heat of the whole body, as well as of its own 
site, is quite certain; but this may be simply by causing general excite- 
ment, especially of the circulation and respiration, and by repressing 
the perspiration and other exhalations, by which the body is naturally 
cooled. It seems, however, quite consistent with analogy to admit that 
inflammation, as a process of increased vascular action, may generate 
heat; and inasmuch as there is an augmentation of the red particles in 
the part, which are supposed to be chief agents in the generation of 
heat (through the oxygen which they supply), we see a reason why the 
calorific process maybe exalted in the inflamed part. Increased heat is 
a very important and valuable symptom of inflammation, since it is more 
constantly discernible than any other, and serves to distinguish inflam- 
mation from congestion and nervous irritation, which may resemble it in 
other symptoms. But to indicate inflammation the heat must be con- 
tinued, and not merely coming in flushes of simple determination of 
blood. Generally, the skin is dry as well as hot; but it may be perspir- 
ing, and yet a temperature, higher than natural, may be sustained. 

432. The swelling of an inflamed part is caused, in some degree, by 
the enlargement of the vessels, but chiefly by the effusions from them, 
and will be, therefore, proportioned to the amount of these; but the 
situation, form and degree of the swelling, will also greatly depend on 
the natural structure of the part inflamed. In serous membranes, the 
vessels being comparatively few, admit of but little enlargement; and 
the effusions, not being retained by complexity of structure, soon over- 
flow externally, and chiefly accumulate in the most dependent parts of 
the serous sac, causing dullness on percussion, and sometimes fluctua- 
tion in the chest and abdomen, and, when in large quantity, distending 
these cavities. Mucous membranes are more vascular and complex in 
structure ; hence the enlargement of vessels early causes some thicken- 
ing ; but the swelling is chiefly due to interstitial effusion in the submu- 
cous tissue (so manifest in coryza and cynanche) ; this effusion, when 
merely serous, soon passes off in the thin flux which attends catarrhal 
inflammations, and the swelling may subside with it; when the effusion 



218 



PROXIMATE ELEMENTS OF DISEASE. 



is more solid, the swelling remains longer, is attended with a more vis- 
cid secretion, and subsides only when this secretion becomes opaque, 
and somewhat fat in its composition. The skin presents great variety 
in the swelling, as well as in the redness caused by inflammation. — 
Sometimes the swelling is diffused and hard, as in cutaneous erysipelas. 
In urticaria, the same hard swelling occurs in spots or patches, and the 
effusion in parts supersedes the vascular redness, causing white centres 
or wheals. In tubercular inflammations of the skin, the redness and 
swelling are still more circumscribed, and the effusion seems to be chiefly 
solid. In papulae, the swelling is even more minute, and confined to a 
point. In blebs and vesicles, the effusion is between the cuticle and the 
true skin, and the swelling is confined to corresponding patches or small 
spots. Inflammation of cellular texture is attended with considerable 
swelling; this being diffused, cedematous, and pitting on pressure when 
the effusion is serous ; being more tense when there is fibrin with the 
serum ; and being hard and subscribed (as in phlegmon) when the mat- 
ter effused is chiefly fibrin. Parenchymatous organs, in like manner, 
are remarkably swelled by inflammation. The liver, kidneys, testicles, 
lymphatic and other glands, attain a large size from the mere distension 
of their blood-vessels ; and we have noticed a similar result from mere 
congestion (§ 293); but inflammation does not last long in these struc- 
tures without causing effusion, which, by various proportions of serum 
and lymph, may cause swelling, varying in its firmness. The lungs, 
from their porous structure, do not swell materially in bulk ; but the 
effusion displaces the air in their cells, thus increasing their weight, and 
if the effusion abound in lymph, converting them into a more or less 
solid mass, like liver (hepatization). 

433. The pain of inflammation is caused by that exaltation of sensi- 
bility (§ 135) which determination of blood produces (§ 333), often in- 
creased by the tension or pressure arising from the swelling. The 
amount of pain will, therefore, depend much on the natural sensibility 
of the part, the degree in which determination of blood predominates, 
and the tension or pressure induced. The severest pain arises where 
these circumstances co-operate, as in inflammation of the pulp of a 
tooth, the sheath of a nerve, the lining of a bony canal, as the auditory 
meatus, &c. In other cases, pain is chiefly felt when the inflamed part 
is pressed or stretched, constituting excessive tenderness. Thus the 
pain of peritonitis is felt on pressing the abdomen, or on straining the 
walls by coughing or vomiting ; the stitch of pleurisy is felt on taking a 
full breath ; the pain of external inflammation and rheumatism, on mo- 
tion, or pressure on the limbs. In enteritis, there may be little pain 
until the intestines become spasmodically contracted in some parts, and 
distended in others, by flatus and other contents ; hence the pain may 
vary, whilst the inflammation remains the same. Parenchymatous or- 
gans and mucous membranes being comparatively soft and yielding in 
texture, are not the seat of much pain when inflamed. In the early 
stage, pain, with heat, may indicate the activity of inflammation, that is, 
the prevalence of determination of blood. In the more advanced stages, 
the pain rather bears relation to the amount of tension from swelling or 



INFLAMMATION — CONSTITUTIONAL SYMPTOMS. 



219 



effusion, and is commonly relieved when this becomes more diffused, or 
ends in suppuration. 

434. Besides pain and tenderness, sensibility increased by inflamma- 
tion sometimes exhibits other modifications, such as feelings of soreness, 
tingling, heat, itching, &c. Peculiar sensations are also excited in the 
organs of special sense when they are inflamed, such as noises in the 
ears, painful and disturbed vision, &c. The peculiar sensibility wnich 
excites the motions of sneezing, coughing, vomiting, micturition and 
defecation, is exalted, w T hen respectively the Schneiderian membrane, 
the lining of the upper part of the air-tube, the cardiac end of the sto- 
mach, the bladder and the rectum, are inflamed. Other sympathetic 
sensations (§ 156) excited by inflammation are peculiar to disease, as 
the pain in the shoulder-blade, with inflammation of the liver ; pain in 
the testicle, with inflammation of the kidney; pain of the glans penis, 
in inflammation of the bladder ; pain of the knee, with inflammation of 
the hip. 

435. Contractile fibre is not itself prone to inflammation ; w T hen the 
parts contiguous to it are inflamed, the effect is commonly first to increase 
its irritability (§ 113), and subsequently to impair it, probably by ex- 
haustion. Thus the heart, w 7 hen its membranes are inflamed, acts first 
with great force and frequency, but subsequently with feebleness and 
irregularity. When the intestines, bladder, or air-tubes are inflamed, 
there is contraction followed afterwards by more or less weakness of the 
muscular fibres of these parts. 

436. Other functions are somewhat similarly affected under the influ- 
ence of inflammation. In inflammation of the brain and its membranes, 
there is commonly at first more or less excitement of the sensorial func- 
tions, causing delirium, hallucinations, and convulsions: afterwards en- 
sue stupor and coma, and paralysis. In the early stage of inflammation 
of the spinal cord, there may be tetanic convulsions ; afterwards follows 
paralysis. Often symptoms of partial excitement are conjoined with 
others of interruption of function ; and this is not extraordinary, seeing 
that inflammation comprises diminished as well as increased flow of blood, 
and the former generally predominates as the inflammation advances and 
effusion proceeds. Inflammation of the lungs causes dyspnoea: that of 
the. stomach interferes with digestion: inflammation of the kidneys sus- 
pends or impairs their secreting power, &c. Further details belong to 
special pathology. 

CONSTITUTIONAL SYMPTOMS OF INFLAMMATION. 

437. The irritation of inflammation frequently extends itself to the 
system at large. The functions of the whole body are more or less dis- 
ordered. The contractions of the heart are more frequent and forcible 
than usual: the arterial tonicity is increased (§ 121); hence the pulse is 
quick and hard : the skin is dry and hot : the appetite and strength are 
impaired : and the natural secretions are diminished and otherwise disor- 
dered. This is inflammatory fever. 

438. Among the most important general effects of inflammation must 
be noticed the change in the condition of the whole blood. We have 



220 



PROXIMATE ELEMENTS OF DISEASE. 



before noticed, that there is an excess of fibrin and of the colorless glo- 
bules in the blood in inflammatory diseases (§ 195); and that the sepa- 
ration and contraction of this fibrin (§§ 203, 4) take place in an unusual 
degree, and produce the peculiar buffed and cupped appearance of the 
clot so remarkable in inflamed blood (§ 208). This excess and separa- 
tion of fibrin displayed in the buffy coat is commonly proportioned to the 
extent of the inflammation and its duration in an active state. This 
would suggest that the change in the blood is altogether produced in the 
blood-vessels in and near the inflamed part: and the increased develop- 
ment of white globules, seen by aid of the microscope (§ 415), (which, 
chemically speaking, is an oxidation of some of the protein,) is a kind 
of demonstration of this production. This supposition derives support 
from the fact, that blood drawn directly from an inflamed part is more 
buffed than that drawn from a distant part.* The excess and separation 
of fibrin is more remarkable in inflammations of serous membranes than 
in those of mucous membranes, or parenchymata, which may perhaps 
be ascribed to the former inflammations being attended with less local 
vascular distention and overflow of the exudation corpuscles and fibrin. 
Acute rheumatism presents the highest degree of the buff and cupping 
of the blood ; perhaps because the inflammatory irritation arising from 
matter in the blood itselff (§ 251) affects a great many vessels, yet with- 
out completely obstructing them, so that determination of blood predomi- 
nates over congestion; and although there maybe much inflammation 
and effusion of the early kind (§ 423), this does not lead to suppuration, 
or other of the more destructive changes which follow inflammation. It 
has been before mentioned (§ 245), that an increased activity of circu- 
lation and respiration might contribute to augment the fibrin of the blood 
in acute rheumatism and other inflammations not impairing the respira- 
tory function; but it was then objected, that the increase of the fibrin is 
sometimes observed in rheumatism without much acceleration of the 
pulse and breath ; and, on the other hand, in fevers in which the pulse 
and breath are much hurried, the fibrin of the blood is even diminished 
(§ 196). And it w r as found, by Andral and Gavarret, that in fevers, the 
occurrence of local inflammation always caused an increase of the fibrin 
in the blood. 

It seems pretty clear, then, that the increase of fibrin, and its more 
contractile and separating quality, originate in the vessels of the inflamed 
part, and must be regarded as an augmentation of the process of nutri- 
tion developed by inflammation. A similar augmentation takes place 
in the vessels of the uterus during pregnancy, when the blood drawn 
generally exhibits a buffed appearance ; and although such an appear- 
ance is not commonly presented by blood drawn from fast-growing chil- 
dren during health, yet in them it is very readily induced by inflammation, 
and the plastic products are unusually copious. It has been mentioned 
(§ 415), that in young frogs, even in health, many white globules are 
seen in the blood-vessels adhering to or moving slowly along their sides; 

* I have observed this even in blood drawn by cupping, on a part inflamed by the pre- 
vious application of a blister. 

f The buffed appearance of the blood in inflammatory dropsy admits of a similar inter- 
pretation (§ 385). 



INFLAMMATION — SYMPTOMATIC FEVER. 



221 



and this appears to be a proof of the activity of the same nutritive or 
plastic process which is exalted to its highest degree in acute inflamma- 
tion. 

439. It has been supposed, that the inflammatory or fibrinous state of 
the blood is the cause of the general excitement constituting the symp- 
tomatic fever accompanying inflammation; but it may be objected, that 
this fever frequently rises high before the blood has begun to exhibit the 
buffy coat, often subsides when the buffy coat is most abundant, and is 
sometimes wholly absent when the blood is both buffed and cupped, as 
in subacute rheumatism. It is very probable, however, that the excess 
of fibrin may contribute to the excitement; and it certainly materially 
affects the duration and products of the inflammation. 

440. In inquiring into the pathology of inflammatory fever, we must 
bear in mind, that it sometimes precedes the distinct development of the 
local inflammation, being, in fact, a general excitement or reaction after 
the disturbing influence of the exciting cause. This is especially the 
case where inflammations are produced by cold, fatigue, and other causes 
which first induce congestion (§ 403). The operation of these causes 
is at first depressing to the whole system ; and the continuance of this 
marks the cold stage of the fever, with weak pulse, coldness of the ex- 
tremities and surface, general pallor, various uneasy feelings, dejection 
of spirits, and depression of strength. Afterwards ensues the reaction, 
beginning with rigors, accelerated pulse and breathing, sometimes vomit- 
ing, and other functional disturbances : soon the skin becomes hot, the 
pulse hard, as well as frequent; uneasy feelings in the head, back, and 
limbs, are experienced, with thirst, loss of appetite, restlessness, and much 
weakness. It is during or after the esl^ablishment of this reaction that 
the local symptoms of inflammation may become prominent. During 
the cold stage, they may have been chiefly those of congestion of the 
affected organ (§ 303), impaired function, with more or less uneasiness; 
but now pain(§ 433), heat(§ 431), and various symptoms of local irri- 
tation (§ 434), ensue; and frequently, as these become developed, the 
general disturbance is somewhat reduced or modified. In eruptive fevers, 
the general disturbance and functional disorder are greatest before the 
eruption (or local inflammation) appears. In inflammations from cold or 
fatigue, the first disorder sometimes resembles that of continued fever, 
•which is changed for simple inflammatory fever as soon as the inflamma- 
tion is pronounced. In other cases, again, chiefly those which originate 
from local irritation (§• 402), the inflammation is developed, and its symp- 
toms are prominent, before the symptomatic fever is excited. Generally 
the fever is in proportion to the severity or active character of the inflam- 
mation ; and if it were always so, we might conclude that the fever is 
the result of a reaction from the disturbance of the circulation produced 
by the inflammation; but we sometimes find inflammation of trifling 
organs, such as the tonsils, attended with a very smart fever; and much 
greater disturbances of the circulation, such as congestions of the lungs 
and liver, take place without causing any fever. It seems more probable, 
then, that the fever accompanying inflammation arising from local irrita- 
tion, is caused by an exciting influence propagated from the inflamed 
part to the heart and arteries through the medium of the nerves. The 



222 



PROXIMATE ELEMENTS OF DISEASE. 



same influence also sustains the inflammatory fever in the cases before 
noticed in this paragraph, in which the first febrile movement seems to 
be the result of reaction. 

441. It still remains unexplained why, in fever, the circulation and 
some functions are excited, whilst others, as secretion, muscular strength, 
and the appetites, are much impaired. We may partly solve this diffi- 
culty, if we may point out that the excitement is not one of a healthy 
kind, being attended with an excessive tonicity of the arteries (§ 121), 
which is the cause of hardness of the pulse, and which may transmit the 
blood through the capillaries too rapidly to permit of its proper changes 
by excretion. It is also possible that the vital powers of secretion (§ 158) 
may be more directly impaired by the inflammation or its cause ; for it is 
certain that, either as cause or effect, imperfect secretion is one of the 
most prominent elements of fever in general. Thus the bowels are 
generally costive ; the urine scanty and high colored; the skin dry; the 
tongue clammy, with thirst; and ulcers or sores, that may have been 
discharging before, now become dried up. So, too, on the subsidence 
of the fever, all these secretions are restored. 

Finally, we may sum up the causes of the symptomatic fever of in- 
flammation under three heads: — 1. Reaction after the depression induced 
by some exciting causes, such as cold, fatigue, &c. 2. Irritation com- 
municated from the seat of inflammation, probably through the nerves ; 
most prominent in irritable constitutions. 3. The altered condition of 
the blood, comprising an excess of fibrin, and a retention of excrementi- 
tious matter; these especially sustain the fever. 

442. The fever accompanying inflammation is generally High — that is, 
attended with hard pulse, hot skin, and general excitement — in the 
young, the sanguine (§ 38) an%. plethoric (§ 279); those, in short, in 
whom the vascular system is naturally active (§ 401). On the other 
hand, it is commonly low — that is, with weaker, though sharp and quick 
pulse, less general heat of skin, and with tongue more foul, and functions 
often rather oppressed or disordered than excited — in persons of phlegmatic 
temperament (40), and in those weak from age, disease, mal-nutrition, 
intemperance, or confinement. The type or character of the fever also 
varies with the seat of the inflammation, and the particular textures 
affected, although the variation is less constant than it is generally repre- 
sented to be. It is commonly stated, that the fever is high in inflam- 
mations of most serous and fibrous textures, and in phlegmonous inflam- 
mation of celluar texture ; that it is low in inflammation of the stomach 
and intestines, kidneys, large joints, and in diffuse inflammation of 
cellular texture ; and that the fever is of an intermediate character in 
inflammation of mucous membranes and parenchymata. Clinical expe- 
rience, however, shows that there are many exceptions to these state- 
ments ; and where the type of the fever is affected by the texture, it is 
chiefly by the intensity of the inflammation and the nature of its product. 
Diffused inflammations, of little intensity, often excite very little fever, 
and few local symptoms. The reverse is the cause of very acute inflam- 
mations, even of moderate extent. 

443. The exciting cause, or some co-operating influence, often mate- 
rially affects the type of the fever. The inflammation occurring after 



INFLAMMATION KESULTS — RESOLUTION. 



223 



serious accidents or burns is often attended with a low fever, the reaction 
being imperfect from the continued depressing influence of the cause. 
The same remark is applicable to the case of inflammation from poisons, 
which are locally irritant, but sedative to the system. Even the long 
operation of cold may so depress the vital pow T ers — especially that of 
the heart (§ 75) — that the reaction is imperfect, and the fever is low ; in 
all these cases the symptomatic fever is typhoid or adynamic (§ 25), 
.with w r eak and unequal as well as frequent pulse, varying heat of skin, 
sometimes w T ith partial sweats ; a much furred, and often dry and brown 
tongue; extreme depression of strength; low delirium, and other nervous 
symptoms. These are indications of disordered state of the blood like 
that induced by morbid poisons (§§ 186, 191) ; and it receives an ade- 
quate explanation in the w r ant of purification and elimination from wdiich 
the blood suffers in its congested and imperfectly circulated state ; and 
the evidence of this change is afforded by the altered state of the blood 
particles, the presence of urea, and signs of incipient decomposition 
which have been observed in the blood in such cases, especially those of 
typhoid pneumonia (§ 25). 

444. In the lower forms of inflammation (§ 442), the fever may be 
remittent or even intermittent: a state of depression alternating with a 
state of excitement, ending with perspiration; and when inflammations 
become chronic, or are of slight character, they may excite no fever at 
all. They generally, however, induce some constitutional disorder, in 
w T hich defective excretion (§ 171) is commonly a predominant element. 
When it is borne in mind that inflammation includes determination of 
blood, it will be obvious that, besides the irritation connected with it, 
there may be more or less exhaustion of t other parts of the body (§ 331): 
the part inflamed being over-supplied with blood, other parts are in want. 
This effect is most obvious in anaemic and debilitated subjects; and to it 
must be ascribed the weak circulation, coldness, disordered functions, 
and gradual emaciation of the body in general, when a part long suffers 
from low inflammation. The blood itself also soon becomes impoverished 
in continued inflammation, losing progressively its proper amount of red 
particles, and the fibrin in protracted cases loses its organizable charac- 
ter, and degenerates into cacoplastic or aplastic matter. 

NATURE AND SYMPTOMS OF THE TERMINATIONS OR RESULTS OF 
INFLAMMATION. 

445. The results or events of inflammation may be comprehended 
under four heads: Resolution, Effusion, (including adhesion,) Suppura- 
tion, (including ulceration,) and Gangrene. It must not be supposed 
that these often occur quite singly, or that they are so separated from 
each other by a very marked line ; but these terms are conveniently 
attached to those results in which each respectively predominates. 

Resolution consists in the cessation of the inflammation, and the speedy 
removal of any slight effusion. As the essential parts of inflammation 
appear to be determination of blood, with obstruction to its flow through 
some vessels; so the resolution of inflammation consists in the yielding 



224 



PROXIMATE ELEMENTS OF DISEASE. 



of the obstruction and the subsidence of the determination, the vessels 
contracting to their normal dimensions. This may be well seen under 
the microscope. Sometimes nothing remains of the inflammation, but 
more or fewer of the white globules adhering to the sides of the vessels; 
but more commonly some vessels are still obstructed, and others con- 
gested, with the motion in them slower than usual, the determination of 
blood (enlargement of the arteries) having ceased. So, commonly, we 
find congestion remain in a part that has been inflamed; and not unfre- 
quently a flux or watery effusion may result from that congestion (§ 375). 

446. Resolution of inflammation may occur spontaneously in slight 
cases; or in consequence of treatment; or from the inflammation being 
transferred to another part. Some inflammations creep to adjoining parts, 
as in the case of erysipelas and some serpiginous cutaneous eruptions. 
Others affect similar textures in different parts of the body; and being 
resolved in one part, appear in another: this happens in rheumatism, 
which affects fibrous textures, and is transferred from limb to limb, or 
joint to joint, by what is called metastasis, or translation. This may be 
fairly traced to the mobility of the peculiar materies morbi (§ 402), the 
cause of the inflammation. A remarkable metastasis of resolving inflam- 
mation is sometimes seen in parotitis, the breast or the testicle becoming 
the seat of the new attack. 

447. The occurrence of resolution is marked by a subsidence of the 
chief symptoms of inflammation: first, of the heat and pain, and, more 
gradually, of the redness and swelling. The heat usually yields to per- 
spiration. The pain becomes gradually easier; and in some parts, as the 
skin, may pass into itching before it subsides. The redness sometimes 
simply fades; more commonly it becomes less florid, and may pass 
through shades of a livid or dusky hue before it vanishes. The swelling 
soon subsides; the effused fluids being so speedily removed by absorption, 
that effusion can scarcely be said to have been a result. Still, in some 
instances, congestion, or some of its results (§§ 274, 350), or nervous 
irritation (§§ 126, 152), remains behind after the inflammation has ceased. 

448. The resolution of any considerable inflammation is marked by a 
reduction of the fever: the pulse becoming softer and less frequent; the 
skin moist with perspiration, sometimes profuse; the urine, becoming 
more copious, abounding in urea, and depositing, as it cools, a plentiful 
lateritious, or branny sediment, consisting of lithate of ammonia. The 
constancy of this last change on the decline of inflammatory fever has 
led to the supposition that it is critical, and determines the removal of 
the disease. The lateritious sediment in the urine is a pretty certain 
symptom of the subsidence of fever, and of the amelioration at least of 
the inflammation which excited it; but it is uncertain how far it is the 
cause or the effect of the improvement. It indicates an increased excre- 
tion of the solid constituents of the urine ; for there is often an excess of 
urea as well as of the lithates ; and comparing this with the scanty se- 
cretion of urine during the febrile excitement, and the decay of tissues 
and blood which is always taking place (§ 254), we can scarcely avoid 
the conclusion that these excrementitious matters had been accumulating 
in the blood from the impaired function of the kidneys during the fever; 
and that now, as the fever subsides, and their function is restored, the 



INFLAMMATION — RESULTS — EFFUSION. 



225 



accumulated matter is thrown off. Now, although the function of the 
kidney must be first impaired to cause the accumulation of the excre- 
mentitious matter in the blood, yet this matter so retained tends to keep 
up the disorder (§§ 68, 171); and it is by means which promote the 
elimination of this matter that we succeed best in reducing febrile excite- 
ment. So, likewise, in cases where the function of the kidneys is per- 
manently impaired byBright's disease (congestive degeneration, § 309), 
inflammatory and other fevers are not readily brought to a termination : 
persons so affected are said to be <f bad subjects," with "broken down 
constitutions;" and they often sink because their excreting organs are 
unequal to the increased task thrown on them. In cases in which the 
resolution of the inflammation is only partial or imperfect, a daily remis- 
sion or alleviation of the fever may take place ; and with it there is usually 
a deposit in the urine, of a pinker or lighter color than the usual brown 
lateritious sediment, and containing, besides lithate of ammonia, purpu- 
rate of ammonia and lithate of soda. 

Effusion {including adhesion). 

449. Effusion we have already found to be a result of inflammation 
(§ 423); but it is not always, like resolution, a termination of this pro- 
cess (§ 427). An abundant effusion of liquor sanguinis, of coagulable 
lymph and serum, of pus, or of inflammatory mucus, usually lowers the 
inflammation — that is, reduces the determination of blood, and may 
diminish the obstruction, but often does not remove it; and the effused 
matter may cause sundry mischievous effects, by compressing, stuffing, 
or obstructing the several structures in which it accumulates. We may 
with advantage pursue the history of effusions, by tracing their changes 
in the chief elementary tissues. 

Serous membranes, being simple in structure, give us the best illustra- 
tion of the history of inflammatory effusion. In acute inflammation, in 
a healthy subject, besides serum, an exudation of fibrin or coagulable 
lymph takes place in a few hours. This fibrin is at first in a semi-fluid, 
ductile state; so that the motion or pressure of the inflamed surfaces 
draws it into bands or threads, and exhibits the same adhesive properties 
w T hich were before noticed, as belonging to one of its elements, the pale 
corpuscles within the vessels (§ 417); or spreads it into films, as we see 
it on the pleura, pericardium, and peritoneum. But if we examine in- 
flamed surfaces which are less exposed to motion or pressure, as the 
looser parts of the auricles of the heart, the serous covering of interlobar 
divisions of the lungs, that of the less projecting parts of the intestines, 
and of the convolutions of the brain, we find the deposit of lymph not 
uniform in a film, but in points forming a granular surface ; which shows 
that either more is effused at some points than at others, or that the con- 
cretion of fibrin having begun in points, chiefly augments around the same 
points. The granules thus deposited vary in size, from that of a grain of 
sand to that of a millet-seed ; but if the deposit increases, they enlarge into 
patches, which may run into one another, often forming a mammillated 
coating of lymph. Even on surfaces which are subject to motion, the 
prevalence of the fibrinous effusion at points is shown by a villous or 
15 



226 



PROXIMATE ELEMENTS OF DISEASE. 



shaggy appearance of the lymph, from this, in its ductile state, being 
drawn into threads projecting from the points where it has first con- 
creted: this is sometimes well seen in the pericardium. In the pleura, 
these inequalities are more obliterated by the rubbing motion of respira- 
tion, or by the pressure of liquid effusion. 

450. The lymph thus effused is (like the buffy coat of inflamed blood) 
at first transparent ; afterwards it becomes yellowish, and more or less 
opaque, but in inflammation of a healthy subject generally retains some 
degree of translucency. In this respect, it contrasts with the product of 
inflammation in unhealthy subjects, purulent and tuberculous lymph, 
which is more opaque. Bat the most important character of healthy 
lymph is its high susceptibility of organization, which character I will 
in future designate by the term euplastic (§ 211). Euplastic lymph con- 
sist of fibrils of fibrin crossing each other in various ways, and mixed 
with numerous exudation corpuscles, both compound (cells with nu- 
clei and granules) and simple (granules and molecules). Now, these 
are also found in the buffy coat of inflamed blood (§ 212); and there can, 
therefore, be no doubt of their identity, and that the blood thus altered 
by the inflammatory process is their source (§ 438). This leads us to 
anticipate what is the fact, that the plasticity of lymph will depend much 
on the good quality of the blood, as well as on the energy of the inflam- 
mation. Healthy blood, which abounds in red particles as well as in 
fibrin, furnishes the most plastic kind of lymph (§ 183); and inflamma- 
tion, attended with the most active determination of blood, (so long as 
the integrity of the vessels is preserved,) separates this lymph in the 
greatest abundance. This lymph already possesses living properties, 
for its materials arrange themselves into the basis of a texture ; but to 
sustain the life of this texture, it must be supplied with blood, and this 
takes place in the wonderful process of the formation of blood-vessels in 
it, which communicate with those of the adjoining parts. 

451. The precise manner in which vessels are formed in lymph is still 
a matter of some obscurity. Mr. Kiernan observed inflamed capillaries 
become varicose, and at points project in pouches and diverticula, and 
stretch into loops. If these give way, the blood would be injected into 
the lymph; and if something of channels were previously formed by the 
arrangement of the fibrils, or the elongation and communication of cells, 
it is quite conceivable that a current would be affected by the vis a tergo 
through several openings, and that a return of the blood would take place 
by a reversal of the weaker currents. Mr. Travers has observed a pro- 
cess somewhat resembling this take place; solitary red particles making 
their way into a bed of lymph globules, and after for some time exhibiting 
an oscillating movement, give way to a current. The oscillatory move- 
ment most probably depends on the pulses of the heart, as in the case of 
those described to occur in obstructed vessels (§ 418). Vogel describes 
the formation of new vessels, and even of the blood within them, as pro- 
ductions of the blastema, independently of adjoining vessels; but were 
this observation exact, we might expect frequently to meet with the ap- 
pearance of vessels with blood in detached masses of lymph, and through- 
out the thickness of large clots accumulating on serous membranes. It 
has been ascertained by Schroeder, Liston, and others, that the new vas- 



INFLAMMATION — EFFUSIONS, PLASTIC AND CACOPLASTIC. 227 



cular channels are at first much larger than the vessels which supply 
them ; they are afterwards contracted by the formation of a basement 
membrane lined with epithelium ; and the whole texture becomes more 
consistent and less bulky, exhibiting a filamentous and cellular structure, 
with nucleated cells scattered through it. These new membranes form 
patches on, or adhesions between, the serous coverings of the lungs, the 
heart, and intestines ; and provided these false membranes are loose, 
flexible, and of moderate thickness, they may cause no disorder. 

452. When the inflammation is of a low character, or when the blood 
is poor in red particles, and especially when these two conditions are 
combined, the solid products of inflammation are less capable of organ- 
ization, and therefore may be called caco-plastic. As the process of or- 
ganization varies in degree, so these products may attain to different 
degrees of structure, forming membranes of a denser, less pliant texture, 
and less vascular than the serous membranes to which they are attached, 
and which they therefore shackle. Thus patches of a kind of fibro-cel- 
lular, or fibro-cartilaginous membrane are formed on the lungs, the heart, 
and the intestines; sometimes with the effect of materially impeding the 
functions of these several organs. Where the effusion of lymph is scanty 
and slow, its granular mode of deposit is more obvious than in the more 
acute disease; for being less ductile, it is less readily spread or stretched 
by the motion of the parts (§ 449). This is well seen in chronic inflam- 
mations of the peritoneum and arachnoid, in which the deposit is almost 
entirely in granules or flattened patches, commonly called tubercles. 
These are generally of a buff or skin color, of firm consistence, and 
sometimes exhibit slight traces of blood-vessels in them ;* but sometimes 
their color is more yellow and opaque, their texture uniform and tough, 
and they are totally destitute of vascularity. These constitute the form- 
ations described under the names cirrhosis and crude yellow tubercle, 
and are the lowest of the organized products. Being, in organization 
and consistency, dissimilar to the membranes on which they are formed, 
they prove a source of irritation and constriction ; and being liable to 
ulterior changes, (shrinking and contraction in the case of cirrhosis; fur- 
ther degeneration and softening in the case of yellow 7 tubercle,) they 
may bring further mischief in contiguous parts. 

453. In some cases, again, more or less of the product of inflammation 
is aplastic, or totally incapable of organization, and is thrown off with 
the liquid in separate large globules filled with granules and molecules, 
constituting pus; or in detached opaque flakes or curds, consisting of 
aggregations of irregular granules, oil-globules, and molecules held to- 
gether by a few fragments of fibrils: such effusions are exemplified in 
the sero-purulent liquid and curdy matter of low pleurisy, pericarditis, 
and peritonitis. It is obvious that such lifeless products must act pre- 

* Mr. J. Dalrymple has observed, that the vascularity of lymph may be seen earlier in 
cachectic and scorbutic subjects, than in healthy lymph. But syphilis and scurvy may mo- 
derate inflammation, without rendering the lymph aplastic: the great impediments to organ- 
ization of lymph are, its bad quality and excessive quantity, and the persistence of inflam- 
mation. In a scorbutic subject, Mr. D. has shown, that even a large coagulum of blood may 
soon become vascular ; but it does not follow that either this or lymph in such subjects can 
be formed into real texture. 



228 



PROXIMATE ELEMENTS OF DISEASE. 



judicially on the containing structures; and the fact might be anticipated 
that they are little susceptible of absorption. 

454. I have mentioned (§ 452) a low form of inflammation, and an 
unhealthy condition of the blood, as causing the cacoplastic character of 
the products of inflammation. It may be added, that the long con- 
tinuance of any inflammation, and its occurrence in subjects in whose 
blood fibrin abounds, while the red particles are scanty (§§ 185, 195), 
will pretty surely render the products cacoplastic or aplastic. At the 
onset of inflammation, its products may be plastic, and the process of 
vascular organization (§ 451) may commence; but if the inflammation 
continues, its product either is thrown beyond the reach of vascular 
communication, or displaces that already effused, and thus the outer 
layer will be in a degenerating condition. Added to this, the pressure 
of the liquid effusion may impede the construction and injection of the 
new membrane, which therefore is degraded into one of the cacoplastic or 
aplastic matters above described. Again, in scrofulous or cachectic 
subjects, the blood, although scanty in red particles, abounds in fibrin, 
and this is readily effused in inflammation ; but it is of low vitality, and 
susceptible of little or no organization.* There is yet another circumstance 
tending to lower the plasticity of lymph, although, according to the ob- 
servation of Mr. Dalrymple, it sometimes accelerates its organization! — 
that is, the admixture of the coloring matter of the blood with it. 
Laennec supposed that contraction of the chest had its origin in hemor- 
rhagic pleurisy only. This is not correct; but I have many times re- 
marked after death, that lymph on the pleura and pericardium, in 
cachectic subjects, is much stained with blood; and where patients with 
similar symptoms have recovered from inflammation, they have been 
affected with structural disease. So far as we yet know, the coloring 
matter does not form a material for organization ; and further, it is very 
probable that in such cases the coloring matter is itself diseased (§ 186). 

455. The more complex structure and secreting properties of mucous 
membranes considerably modify the form and appearance of the products 
of their inflammation. But, according to Gerber, Henle, and Gruby, 
they microscopically consist of pus and mucus globules, granular cells, 
granules, and molecules, together with more or less amorphous and glu- 
tinous mucus and scales of epithelium. I must add, however, that in 
the early stage serum is present, manifest by the saline taste and coagu- 
lability by heat; and at an advanced stage, the mucus acquires an in- 
crease of fatty matter. 

Irritation of mucous membranes merely causes a flux (§ 379), that is, 
the natural mucous secretion, more copious, watery and saline than 
usual, and containing fewer globules. But if the irritation be continued, 
and inflammation follows, the secretion is at first diminished by the 

* When a coagulum of fibrin is retained long in a vessel without becoming organized, it 
loses its structure, and softens into an opaque semifluid matter, which long was mistaken 
for pus; but Mr. Gulliver has shown that it consists of much smaller particles, mere irregular 
granules. In this state it bears the closest general and microscopical resemblance to mature 
and softened tuberculous matter. It appears to me, that certain softened tuberculous ap- 
pearances, met with in the lymph of serous membranes and parenchymata, are similar in 
their nature. 

| Medico-Chirurg. Trans., 1840, p. 212. 



INFLAMMATION — RESULTS — EFFUSION. 



229 



effusion of serum and pale corpuscles into the interstices of the mucous 
and submucous texture, which causes more or less thickening or swelling. 
Soon, however, the effusion overflows to the surface in the form of a more 
or less viscid, saline-tasted liquid, containing more globules and epithe- 
lium scales;* and as the inflammation becomes more intense, the globules 
predominate, and the mucus becomes more scanty, but it is still very- 
viscid. On the first decline of the inflammation, the mucous and saline 
matters diminish, and the globules compose the chief mass of the secre- 
tion, and give it the yellowish or greenish opacity seen in " concocted" 
sputa ; and this opaque matter is afterwards gradually replaced by the 
natural mucous secretion. In many cases, especially in young subjects, 
and others in whom the inflammation penetrates to the submucous cellu- 
lar texture, fibrinous matter is thrown out, forming films or shreds of 
lymph, or giving a fibrous or filamentous appearance to the mucus; 
but this fibrin very rarely becomes organized on mucous membranes, 
because their secreting apparatus and its product lie between the lymph 
effused and the vascular structure. Hence the exudation corpuscles of 
inflammatory mucus are degenerating or aplastic, and constitute the 
opacity of viscid mucous, muco-purulent, purulent and shreddy fibrinous 
matters exuded by inflamed mucous membrane. If inflammation per- 
sists in a mucous membrane, the globules continue to abound in the 
effusion, commonly rendering it opaque and purulent ; and the natural 
mucous secretion being impaired, the product is more diffluent. But 
inflammation rarely continues long over a great extent of surface ; it is 
confined to patches, which yield their opaque effusion whilst other parts 
may be secreting natural mucus. Hence the compound appearance of 
the secretions in chronic inflammations of mucous membranes, (bronchi- 
tis, mucous enteritis and cystitis.) 

Sometimes, interstitial effusion, which takes place at the commence- 
ment of inflammation of mucous membrane, is not entirely removed by 
the subsequent discharge. In such cases, there may remain a perma- 
nent thickening of the mucous and submucous texture, which is the 
cause of the indurations and strictures which inflammation sometimes 
leaves in the intestines and urethra ; and, to a less degree, in the air- 
passages. This, however, it must be observed, is the result of inflam- 
mation, rather of the sub-mucous cellular texture than of the mucous 
membrane itself. 

456. Inflammation of the skin presents great varieties as to the amount 
and kind of its products. The full consideration of these would lead us 
into the pathology of skin diseases, a subject replete with interest and 
practical importance, although sadly neglected amidst the artificial dis- 
tinctions of writers on cutaneous diseases; but the subject is too wide 
to be discussed here. 

Some of the effusions in and from the skin have been glanced at under 
the head of the symptoms of inflammation (§ 432). It may now be 
added, that these effusions may consist of clear serum, with few exuda- 
tion corpuscles and molecules, as in the liquid of blisters and blebs, and 

* Gruby; Morphology of the Pathological Fluids. Translated by Dr. Goodfellow. (Mi- 
croscopical Journal, Nos. 19 — 23.) 



230 



PROXIMATE ELEMENTS OF DISEASE. 



eczema, which dries into thin scabs; or of milky serum, more abound- 
ing in the corpuscles, which dry into thicker scabs, as in herpes, rupia 
simplex, &c. ; or of liquor sanguinis and purulent serum, with more nu- 
merous corpuscles, which form very thick, yellow, or brown scabs, as 
in rupia prominens, impetigo and ecthyma; or the effusions may be 
chiefly solid, and into the substance of the dermis, as in tubercular in- 
flammations and incipient pustules. In all cases of inflammation of 
the skin, there is an increased production of epidermis, which is some- 
times thrown off in scales, with the scabs ; or in a peeling of the cuti- 
cle; or thickens, and forms a hard covering, liable to clefts, and sore 
ulcerations, as in psoriasis, inveterate eczema, &c. 

457. Inflammatory effusion into the cellular texture consists of serum, 
with more or less of the exudation corpuscles and fibrin. In diffuse 
erysipelas, or cellulitis, the fibrin is deficient, and the corpuscles either 
are in moderate numbers, or else are degenerative (purulent). In phleg- 
monous inflammation there is more fibrin, which circumscribes the effu- 
sion, and causes a harder swelling ; and the pressure of this, with a 
continuance of inflammation, may lead to suppuration or sloughing. 

458. Effusions from inflammation of parenchymatous organs resemble 
those from inflammation of cellular texture ; but the parenchymata in 
general being very vascular, as well as yielding, the solid effusion may 
be very copious, without causing the pressure or tension that leads to 
suppuration and gangrene. The lymph effused exhibits, in regard to 
plasticity, the same varieties which we have described in the products 
of serous membranes, (§ 450, et seq.) But inasmuch as lymph effused 
in the parenchyma of an organ would greatly interfere with its function, 
we rarely find it to become organized, except in limited portions, which 
thus remain solid and dense. More usually, the matter deposited is gra- 
dually removed by absorption or secretion after the inflammation declines ; 
or if the inflammation continues, the exudation globules and lymph are 
converted into, or replaced by, various kinds of pus or tuberculous mat- 
ter — consisting of degenerated corpuscles, granules, and fat globules. 

459. Effusion so closely attends the process of inflammation, that the 
symptoms of effusion have been comprehended in those of inflammation. 
Swelling, pressure, obstruction, irritation, consolidation, displacement, 
and various functional, as well as structural disorders, may arise from 
the presence of effused matter. Hence the occurrence of effusion may 
aggravate some of the symptoms of inflammation, whilst others may be 
more or less relieved by it. Where a copious effusion takes place, the 
pain, heat, redness, and fever, are commonly reduced ; for the vascular 
and nervous excitement and determination of blood are lessened; but 
the local or visceral disorder may be increased. The pulse may be as 
frequent, but it is less hard and full; the fever less constant, but it may 
continue in a lower degree, or assume a remittent or hectic form. The 
relief by effusion is greatest in slight inflammations, or where the effused 
matter can be thrown off' from the body, as in the case of mucous mem- 
branes; but there may be much irritation and exhaustion of strength in 
the process of throwing it off, (as in cough and expectoration, diarrhoea, 
purulent micturition, &c. ;) and these will be more harassing where, as 



INFLAMMATION — RESULTS — SUPPURATION. 



231 



we have found is sometimes the case, the effusion does not remove the 
inflammation. 

Suppuration and Ulceration. 

460. The formation of pus among the products of inflammation has 
been several times noticed (§§ 424, 453, 455, 457, 458). Pus is an 
opaque greenish or yellowish white liquid, of creamy consistence, little 
odor, of specific gravity varying from 1030 to 1033. It is chemically 
composed of water, deutoxide of protein forming the cell walls, tritoxide 
of protein and albumen in solution, fat, osmazome, and other extractive 
matter, and the same salts as those in the blood. According to Gerber, 
mature pus contains more fat and less albumen than that recently formed. 

Microscopically, pus consists of a limpid serum, and very numerous 
globules of pretty regular size and form. These globules have much 
resemblance to granular cells or exudation corpuscles; but they are 
larger, and are more distinctly and constantly provided with a cell wall 
and nucleus, in addition to granules and molecules. Vogel describes 
their form to be in general spherical; but sometimes irregularly rounded 
or oval: their cell wall is commonly opaque and somewhat uneven from 
being studded with minute granules. Acetic acid renders the walls 
transparent, and brings into view their nucleus, which, under the action 
of the acid, takes the form of from one to five somewhat elliptic disc- 
shaped bodies clustered, and attached to the interior of the cell. The 
existence of the cell in most pus globules, is also made clear by the 
action of distilled water, which causes the cell to dilate (by endosmosis) 
to double its former size; and the larger granules or nuclei swell also, 
which shows their vesicular nature. Pus globules are larger than the 
general size of exudation corpuscles (§ 424), and exceed in size the 
blood-discs (Gulliver). According to Mr. Addison, they measure from 
Woo *° t^oo °f an i ncn -* Besides, in size they commonly differ from 
other exudation corpuscles in being more distinctly vesicular, and con- 
taining a fluid, as well as granules: their more readily swelling, burst- 
ing, and shedding their contents under the influence of water or potass 
(Addison), may be referred to the same difference. In some instances, 
Vogel admits pus globules to be devoid of a distinct cell wall, as I have 
stated to be the case with some white or granular corpuscles, and the 
only distinction of this kind of pus corpuscle, is in its exhibiting the 
peculiar trefoil, or cordiform nucleus under the action of acetic acid. 

461. Another distinguishing character of the pus globules is their want 
of cohesion; and in proportion as they predominate, they impair the 
consistence of fibrin or mucus with w T hich they may be combined. 
In this respect they contrast remarkably with the white corpuscles, which 
both within and without the blood-vessels we have noticed to manifest 
a remarkably adhesive and cohesive property. This and the other differ- 
ences may be explained on the supposition of the more gelatinous or 

* Pus is not produced in birds, or in cold-blooded animals: the reason of this is not un- 
derstood, as the exudation corpuscles do not materially differ from those of mammalia. A 
careful investigation of the products of inflammation in birds, as well as in quadrupeds, 
would probably throw much light on the true nature of pus and lymph. 



232 



PROXIMATE ELEMENTS OF DISEASE. 



semi-solid parts of the white corpuscle becoming completely fluid, whilst 
the cyst becomes more solid and tougher than before; such a change 
would account for the vesicular form and incohesive properties of the 
globules of pus ; and the extension of a similar change to the larger of 
the contained granules, would equally convert them into minute cells, 
which have the appearance of nuclei, with the usual endosmotic proper- 
ties. This liquefaction accompanying the formation of pus, is not con- 
fined to the contents of the pus globule, nor even to the lymph and other 
products of inflammation; it extends to the containing vessels and tex- 
tures, which are softened, disintegrated, and removed, in proportion as 
the suppurative process proceeds. In complex textures therefore, whence 
the pus cannot escape, this process consists not merely in the formation 
of pus, but also in its substitution for more or less of the inflamed texture : 
for this reason suppuration, more than effusion, may be called a termina- 
tion of inflammation, for the inflamed vessels are in great part destroyed. 

The chemical change which accompanies and probably causes this 
disintegration and liquefaction in the formation of pus, according to the 
researches of Mulder, seems to be an increased oxydation of the protein, 
whereby it passes from the state of solid deutoxide to that of tritoxide, 
which is readily soluble in water, or serum. But this further oxidation 
and solution implies also a reduction of vitality in the exuded corpuscles, 
which thus lose their organizing power, and degenerate into a loose 
aplastic material. "We shall find that the circumstances which promote 
suppuration, the nature of the process, and the symptoms which accom- 
pany it, exactly correspond with this view of the subject. 

462. The circumstances which determine suppuration as a result of 
inflammation, are chiefly three: — 1. A certain intensity and duration of 
the inflammation; 2. The excess of air to the part; 3. A peculiar con- 
dition of the blood. 

1. Intensity and continuance of inflammation comprise the persistence 
of the two chief elements of the process, determination of blood and 
obstruction (§ 419) ; and as we have found that the physico-chemical 
effect of this is first to direct the force and exaggerate the influence of 
the red particles which convey oxygen, on the liquor sanguinis, so that 
more of its protein passes into the state of solid deutoxide; a material 
fitted for organization and reparation ;— so we may infer that the exces- 
sive degree or continuance of the same process may overdo the change, 
give chemical properties an ascendency over the vital powers ; and by 
turning the most recently formed solid into a fluid tritoxide, it may effect 
a work of separation and destruction which may involve the blood in the 
obstructed vessels, and extend to the albuminous matter of the contain- 
ing living texture. Such a result is more likely to ensue in complex and 
highly vascular structures, in which the effused matter is retained in 
intimate contact with the blood-vessels : hence, intensity and continuance 
of inflammation pretty surely lead to suppuration in the true skin, cell- 
ular textures, glands, and most parenchymatous organs. In serous and 
fibrous membranes, on the other hand, suppuration is a rarer result, be- 
cause the vessels are few, and the effused corpuscles less within their 
influence. In partial external inflammations, suppuration may often be 



INFLAMMATION — RESULTS — SUPPURATION. 



233 



prevented by pressure, which diminishes the determination of blood, and 
therefore, reduces the oxygenating influence. 

2. The access of air to a wound or to a serous membrane is well 
known to promote the formation of pus ; and it doubtless chiefly acts, 
by directly supplying oxygen, and converting the fibrin and part of the 
exudation corpuscles into the soluble tritoxide of protein; but air may 
also operate as an irritant on a serous membrane or abraded surface, 
increasing the intensity of the inflammation. A limited access of air to 
a large quantity of pus leads to a decomposition of the matter and the 
production of sulphuretted hydrogen, which acts as a deleterious poison 
on living structures. 

3. That a peculiar condition of the blood promotes the occurrence of 
suppuration after inflammation is obvious from the readiness with which 
all wounds, scratches, and pimples fester, and inflammations of no 
peculiar intensity and in various structures early lead to the formation of 
pus. This state of the system has been called the suppurative diathesis, 
and is presented in cachectic or ill-conditioned subjects, the quality of 
whose blood has been injured by mal-nutrition, imperfect excretion 
(§§ 171, 187), or by the direct operation of some morbid poison (§§ 258, 
296) such as that of erysipelas, confluent small-pox, glanders, &c. But 
the most efficient cause of the suppurative diathesis is the abundant pre- 
sence of pus itself in the blood (pyaemia), as in cases of phlebitis, dif- 
fused suppuration, &c. ; and it is most probable that this cause really ex- 
ists in the examples above mentioned ; for Mr. Gulliver and others have 
detected pus globules in the blood in many such cases; and there is 
good ground to suppose that in all cases of suppuration some of the gra- 
nular corpuscles are converted into pus globules within as well as with- 
out the vessels; but for reasons that will afterwards be explained, this 
takes place only to a very limited extent under ordinary circumstances. 
The conversion of the white or exudation corpuscle into the pus globule 
always implies a loss of vitality; and therefore a peculiar proneness to 
the change (independently 'of intensity of inflammation and exposure to 
air) indicates a feeble state of the vital powers, which are unequal to 
resist chemical affinities. In extreme cases this tendency shows itself by 
the occurrence of gangrene, w 7 hich often supervenes in the worst, form 
of pyaemia, as in malignant erysipelas and glanders. It is, therefore, 
quite intelligible that pus, either in a part, or in the blood at large, may 
act in the mode of a chemical ferment, promoting the formation of more, 
and tending to degrade the plasma of the blood from that organizable 
condition in which it can repair breaches or sustain the nourishment of 
the body. 

These considerations will throw much light on the further process and 
symptoms of suppuration. 

463. The process of suppuration strongly illustrates the opposite cha- 
racter of the elements of inflammation before alluded to(§ 421). The 
obstruction to the passage of the blood through the capillary vessels of 
an inflamed part, and the increase of this obstruction by the pressure of 
matter effused by those vessels that are the seat of determination, reduce 
the vitality of the tissues to so low a degree, that they are unable to with- 



PROXIMATE ELEMENTS OF DISEASE. 



stand the chemical solvent power of the effused fluids,* exalted as it is 
by high temperature. The textures are therefore gradually disintegrated, 
dissolved,! an d absorbed away, whilst the exudation corpuscles, swelling 
into pus globules, occupy their place, and continue to be effused and de- 
veloped by the vessels which are still the seat of determination of blood. :f 
This assumes that absorption is still active in an inflamed part ; and the 
assumption is warranted by the fact, that the absorbing vessels, veins, 
and lacteals, remain perfectly free : and the very occurrence of increased 
pulsation and flow in communicating and contiguous vessels (§ 413), will 
promote the exosmosis of fluid matter by the absorbent vessels. That 
the pus globules should remain unabsorbed will not appear extraordinary, 
when their large size is taken into account (§ 460), and that their cysts 
are not dissolved by their proper fluid, having acquired a remarkable 
degree of toughness. Their large size is wholly opposed to the notion 
that they are effused from the blood-vessels as pus globules ; but their 
arising from the exudation corpuscles easily accounts for their appear- 
ance in the midst of lymph, and other products of inflammation, which 
they supersede as they enlarge and multiply. Thus the combination of 
apparently opposite results, which has been considered so inexplicable, 
— excited and lowered action, increased secretion and increased absorp- 
tion — admits of an explanation in exact accordance with all the pheno- 
mena. 

464. The amount and extent of the process of suppuration varies in dif- 
ferent cases. In cellular and parenchymatous textures, it sometimes occurs 
as purulent infiltration, not circumscribed by lymph, but leaving the tex- 
ture much softened, and partially removed. This diffused kind of suppura- 
tion is to be referred, either to the porous nature of the organ (as with the 
lungs) not admitting an effusion of lymph sufficient to limit the suppuration, 
or to a purulent diathesis or disposition in the blood (§ 462). In most 
cases, the process of suppuration is limited around by solid effusion, 
which may be either the remains of the earlier product of the inflamma- 
tion, or it may be thrown out expressly for the purpose of defending the 
adjoining structure from the operation of the pus, which is obviously a 
noxious matter. A collection of pus thus circumscribed is called an 
abscess ; and when mature, it represents the perfection of suppuration. 
The blood-vessels of the inflamed part are destroyed like other textures; 
but their supplying trunks are obstructed by lymph ; whilst the adjoining 
capillaries, which remain pervious, become dilated and varicose on the 
walls of the abscess, which are lined with a coating of organized lymph, 

* That the liquid of pus can chemically dissolve dead animal matter was proved by J. 
Hunter, who found that pieces of raw meat were dissolved in abscesses, or even in pus kept 
warm out of the body. The experiments of Sir C. Wintringham show that other animal 
fluids have a like property. Dr. Prout notices similar facts. This solvent property we have 
now reason to ascribe chiefly to the formation of the soluble tritoxide of protein. A similar 
change takes place during the cooking of meat ; so that the old expression concoted matter is 
not altogether metaphorical. 

f The idea that the removal of textures in suppuration is owing to their death, originated 
with Dr. Billing. (See his "Principles of Medicine.") 

J That absorption is increased in an inflamed part is further proved by a direct observa- 
tion of Kaltenbrunner, who watched the gradual disappearance of the pigment spots in the 
frog's web. This, however, was not suppuration, as that process does not occur in cold- 
blooded animals. 



INFLAMMATION — RESULTS — ABSCESS. 



235 



the vessels in which continue to secrete pus ; whence this lining is called 
the pyogenic membrane. As the pus increases, the abscess becomes 
enlarged, generally towards some cutaneous or mucous surface, where 
it is said to point ; the skin or membrane ulcerates, and the pus is dis- 
charged. The direction which the abscess takes, seems to be that in 
which there is least resistance ; the parts here are more stretched than 
others; and from being stretched, their vessels are more obstructed, so 
that they cannot maintain the vitality, nor throw out the same amount of 
protecting lymph, which limits the extension of the abscess in other 
directions. Fibrous and other hard textures resist the progress of ab- 
scesses, and the escape of pus. Serous membranes, by their ready 
plastic process, first adhere together, and then often give passage to the 
contents of an abscess through them, without any pus escaping into their 
sac. Thus, abscesses of the liver and kidney make their way across 
the peritoneum into the intestines, through the walls of the abdomen, 
and even through the diaphragm, pleura and lungs. Where pus from an 
abscess does make its way into a serous sac, it causes severe irritation, 
and, commonly, fatal inflammation. 

465. After an abscess has opened, it may continue to discharge pus, 
pure, or diluted with serum or sanies ; but in healthy subjects, a pro- 
cess of healing takes place by an increased effusion of lymph, and 
growth of new vessels in it, in the form of granulations, throughout the 
interior of the abscess. Pus is still formed by the superficial layer of 
exudation corpuscles degenerating or swelling: and a free vent must be 
given to this pus, until the growth of the granulations, and the contrac- 
tion of the walls, shall have obliterated the cavity of the abscess, and 
left no more room for the pus to accumulate. 

466. Ulcers sometimes arise from abscesses; an abscess that has dis- 
charged its contents is, in fact, an ulcer. But more commonly, ulcers 
originate from limited inflammations of the skin or mucous membranes, 
in which the natural cohesion of the skin is so much impaired by the 
solvent action of the effusions on the tissue, that it is broken up at one 
or more spots, and either carried aw T ay in the pus discharged, or absorbed. 
There is then left a solution of continuity or excavation, the bottom and 
edges of which continue to discharge pus, or a serous fluid, mixed with ex- 
udation corpuscles, and, sometimes, blood particles. Ulcers may tend to 
spread by the same process ; or to heal by the effusion of fibrin on their 
walls, and the extension of vessels into this lymph in the form of granu- 
lations, which are the materials of the new texture. Ulcers, besides, pre- 

- sent a great diversity of character in the nature of their secretion, and the 
condition of their walls, as well as in the symptoms w 7 hich they pro- 
duce ; .these circumstances constitute the varieties of ulcers described in 
surgical works. 

The cause of ulceration is commonly local, the inflammation suspend- 
ing the normal nutrition of a part, and promoting its solution (§ 460, 3). 
It is often preceded by induration from the amount of solid deposit; and 
the ulceration commences in the centre of the induration, because the 
nutrient influence of the vessels is most reduced by the pressure at that 
spot. But a very poor condition of the blood (hypinosis, § 196) is 
often much concerned in determining this result, and seems to be 



236 



PROXIMATE ELEMENTS OF DISEASE. 



sometimes sufficient to cause ulceration, without any distinct previous 
induration, or even inflammation; the parts that suffer being either 
those which have become congested by posture (as in cachectic ulcera- 
tions of the legs), or those most remote from the nourishing influence of 
the blood; such as the non-vascular textures, the cornea, cellular parts 
of cartilages, &c. In cases of extreme anaemia (§ 268), where the fibrin 
and albumen of the blood are very defective (§ 197), ulcers of this de- 
scription arise, and are to be counteracted by measures the very opposite 
to antiphlogistic. A similar result was found, by Magendie, to ensue 
in animals fed on sugar, starch, and other non-azotized articles of food. 
In these instances, the ulceration and destruction of textures may be 
referred to prevalence of the solvent power exerted by the oxygen of the 
blood on materials whose vital power of resistance (§ 16) is much re- 
duced, and for which there is no renovating supply in the plasma of the 
blood. 

467. Softening of textures may arise from the same change which, 
in a greater degree, and more circumscribed space, causes ulceration. 
It has already been noticed as an effect of inflammation (§ 427) ; and it 
may now be added, that the condition of the blood which disposes to ul- 
ceration sometimes leads to the more diffused operation of the same change 
in the softening of textures. Thus softening of the brain, liver, muscle, 
and mucous membrane, sometimes results from anaemia, or imperfect 
supply of blood in these parts, or from spancenia or impoverished condi- 
tion of that blood (§ 197); and inflammation, which further impairs or 
deranges the supply, may immediately determine the softening process. 

Local Symptoms of Suppuration. 

468. It may be gathered from the previous description, that suppura- 
tion is a work of destruction, and therefore is, in some measure, to be 
contrasted with effusion of lymph, which is intended to be a process of 
construction or reparation. Pus is totally aplastic itself; it is formed at 
the expense of the plastic product of the vessels, and the liquid of pus 
seems to act as a solvent or septic on textures when their vitality is re- 
duced. Although, therefore, suppuration is often useful in terminating 
inflammation, and in removing superfluous products and parts injured by 
it or its causes, yet suppuration must be viewed as a depressing and ex- 
hausting process, and its product as having a noxious character: the 
symptoms which accompany it will be found to correspond with this 
view. 

469. The occurrence of suppuration is marked by a diminution of the 
heat, pain, and other signs of irritation and increased action in the part. 
The pain often becomes throbbing, as if the external pressure on some 
of the larger vessels had yielded, and these become expanded at each 
pulse. The swelling becomes softer; and if within the reach of touch, 
is felt to be first more yielding under the finger, and afterwards to present 
the fluctuation of fluid matter. The redness present in inflammation is 
also diminished, being wholly superseded by the pale yellow of purulent 
effusion in the central parts of the suppurating mass, being mottled by 
it in others, and retaining its deep character only in those parts of the 



INFLAMMATION — RESULTS SUPPURATION — SYMPTOMS. 237 



circumference where the suppuration has not reached. In external in- 
flammations, the redness of the skin becomes deeper before suppuration; 
but when this process reaches the skin, a pale spot is seen, which by its 
fluctuating feel indicates the approach of the abscess to the surface. 

The great reason of the alleviation of the symptoms of inflammation, 
on the occurrence of suppuration, is the diminution of tension and hard 
swelling, which chiefly cause the pain and irritation (§ 433); and where 
suppuration takes place amidst unyielding parts, as under a fascia or 
within a bone, the tension is increased rather than lessened, and the 
symptoms of pain and irritation may be more severe than ever. The 
powerful influence of hydraulic pressure in causing the injection of a 
liquid into a compact texture, and the swelling of the pus globules by 
endosmosis after their first formation, will assist in explaining the effusion 
of pus under a dense periosteum or theca, and the extreme pain and 
irritation which it produces. The free secretion of pus from mucous 
membranes relieves inflammation, and removes the submucous deposit 
(§ 455). 

General Symptoms of Suppuration. 

470. The influence of suppuration on the system is manifest in the 
lowering of the inflammatory fever; the pulse losing its strength, but 
retaining its frequency; the heat subsiding, or alternating with chills and 
sweats; the general redness being succeeded by paleness, or a hectic 
flush; the urine depositing a pale or pinkish sediment;* and the general 
excitement giving place to weakness and exhaustion. The amount of 
the change will greatly depend on the extent of the suppuration, and the 
importance of the organ affected ; but another chief circumstance deter- 
mining the effect of suppuration, and proving the noxious influence of 
pus on the system, is the difference between those suppurations that are 
diffused without a circumscribing barrier of lymph, and those that are 
thus limited, or are thrown off at once from the body. 

In some cases of inflammation of the cellular texture, skin, and of 
serous membranes, pus is formed with little or no previous exudation of 
lymph, and produces in the system the most formidable effects. The 
pulse becomes very frequent and weak ; the tongue brown and dry, or 
coated with an offensive fur, and tremulous; sweats break out profusely; 
the urine is scanty, high-colored, and foetid, sometimes it is suppressed ; 
a putrid diarrhoea occasionally occurs ; hiccup comes on; the mind is 
much depressed, or excited by occasional delirium; the patient's manner 
and motions are agitated and restless ; the breathing becomes hurried and 
sighing; and death may ensue in from one to four days from the com- 
mencement of these symptoms. Similar results ensue in suppurative 
inflammation of veins; and in injuries of the head ending in suppura- 
tion, communicating with some of the venous sinuses; and they have 
been known to follow where an external abscess has suddenly subsided 

* The occurrence of urinary sediments after suppuration has been noticed by Schonlein as 
a constant phenomenon; but such sediments are also observed after inflammation without 
suppuration, and must be regarded as the debris of plastic matter and textures wasted during 
the inflammatory process. 



238 



PROXIMATE ELEMENTS OF DISEASE. 



without opening, and in cases in which the discharge from a large sup- 
purating wound has suddenly ceased. On opening the body after death, 
in a few such cases, nothing peculiar has been found, except a general 
fluidity of the blood, and the gravitative congestions and stains which 
that fluidity induces (§ 196). In most instances, however, there are 
found in some of the viscera, particularly the lungs and liver, purulent 
deposits, as they are called ; collections of pus, generally confined to 
lobules or portions of lobes of these viscera, with more or less inflam- 
matory injection and deposition of lymph around the collections. In these 
cases, there can be little doubt that pus in some way is conveyed in the 
circulation ; and being arrested in the lungs and liver, leads to the forma- 
tion of more (§ 462), — whether by the production of suppurative phlebitis, 
as supposed by Cruveilhier, Dance, and others, is doubtful, — and that 
the pus in the blood is the cause of the formidable symptoms and results 
above noticed. In several such cases purulent matter has been detected 
in the blood in considerable quantities, not only by the aid of the micro- 
scope, but by the pus globules forming a visible layer on the surface of 
the red particles. From the experiments of M. D'Arcet,* it is probable 
that the poisonous influence of purulent matter arises from chemical 
changes induced by air in its serosity (§ 460) ; but that obstruction to the 
circulation in the lungs and liver, and consequent circumscribed inflam- 
mations of these organs, result from aggregation of masses of the debris 
of the globules of pus contained in the blood. 

In those instances of the abundant presence of pus in the blood, it is 
not to be supposed that it is absorbed through the entire walls of blood- 
vessels; the large size of the pus globule, as before noticed (§ 463), for- 
bids that supposition ; but unusual channels of entry into the vessels have 
been in several cases discovered, as in the instance above-mentioned of 
an abscess in the skull opening into one of the sinuses; to which may 
be added that in suppuration in bones generally, the pus may find en- 
trance through the open venous canals ; and in wounds of the neck it 
may be drawn in through the large divided veins under the suction influ- 
ence of inspiration. Suppurative phlebitis has been already mentioned 
as an obvious cause of pyaemia. Lastly, we must again advert to the 
fact, first established by Mr. Gulliver, that pus globules appear in the 
blood in other cases of severe inflammation and suppuration where no 
opening into the veins is known to exist. In these instances, as before 
stated (§ 463), the pus globules are probably formed within the vessels of 
the inflamed part ; and these increase and produce symptoms of pysemia 
only in cases in which the vitality of the blood is impaired, and there is 
a proneness to the formation of pus from trivial causes (§ 462). To the 
latter group I would refer several instances of pyaemia with the bad 
symptoms before mentioned, which I have seen after scarlatina, and in a 
few cases of acute albuminuria and typhoid rheumatic fever. Probably, 
too, malignant erysipelas and metroperitonitis belong to this class. 

471. The preceding observations prepare us for the fact that, besides 
the extreme effects above noticed, extensive local suppurations cause 
various symptoms of depression or low irritation. Of this kind are the 

* " Heche rches sur les Absces Multiples," &c.; and Brit, and For. Med. Rev., Jan. 1843. 



INFLAMMATION — RESULTS — GANGRENE. 



239 



rigors often experienced at the commencement or increase of suppuration. 
Dr. Billing plausibly ascribes this to the system sympathizing at the 
death of the part which is under destruction by the suppurating process; 
but the rigor not being always present suggests rather that the presence 
of a certain amount of pus in the blood might be its cause ; and this may 
induce the shivering merely as a depressing agent, or very probably by 
directly interrupting the calorific process by the withdrawal of a portion 
of the oxygen which sustains it (§ 461). This latter notion is counte- 
nanced by the remarkable and sudden fall of temperature which often 
accompanies the extensive formation of pus. 

Again, when suppuration continues long, even if it be discharged 
outwardly, as in extensive wounds, or ulcerations of the skin or mucous 
membranes, there is great wasting of strength and flesh, with a partial 
febrile irritation of a peculiar kind, called hectic fever. This is remittent 
in its symptoms, the exacerbations recurring once or twice daily, begin- 
ning with chills and depression, and followed by frequent pulse, partial 
heats, especially of the cheeks, hands, and feet, and ending in a profuse 
perspiration. As this proceeds, the body more or less rapidly wastes, 
and the colliquative sweats and diarrhoea, vomiting, and aphthae of the 
mouth, are so many proofs of the rapid decomposition and removal of 
the various structures, which tend to hasten the fatal result. The febrile 
part of hectic is most observed in the young and irritable ; but the 
depressing and exhausting effect of extensive suppuration is seen in all 
cases, in progressive emaciation and cachectic pallidity. 

472. The matter of abscesses is laudable or healthy in proportion as it 
is thick and opaque, but uniformly liquid and free from smell ; for although, 
even in this state, it is fit only to be expelled from the body, and is prone 
to decomposition, yet if excluded from the air it will remain unaltered 
for a long time. The formation of such pus is pretty sure to be attended 
with a protection of lymph, and it is far less noxious than ill-conditioned 
sanious matter, the fcetor of which indicates that decomposition has 
already begun. 

GANGRENE. 

473. Gangrene, like the more complete forms of suppuration, may be 
well called a termination of inflammation, for the inflammation ends in 
the death of the part. In suppuration, the dying textures are softened 
and displaced by pus as fast as they die ; in gangrene, the textures die 
more extensively than pus is formed, and they run into decomposition 
without being removed. In some cases, especially in limited gangrene, 
the dead portion is dissolved away at its circumference by the inflamma- 
tory exudation from the living parts, and it is thus separated or sloughed 
from them ; but if the dead portion be extensive, and the power of the 
living parts low, the separating process will not be accomplished before 
decomposition ensues, which produces the changes called gangrene and 
sphacelus. 

474. The circumstances which caus* inflammation to terminate in 
gangrene are those which completely suspend the circulation of the part 
(§ 273), and those which greatly injure the composition of the blood or 



240 



PROXIMATE ELEMENTS OF DISEASE. 



directly destroy vital properties. The circulation in a part may be 
destroyed by long-continued pressure, by severe contusion, laceration, or 
other mechanical injury, by extreme heat or cold, by strong chemical 
agents, by the excessive pressure of the solid matter effused in the early 
stage of inflammation (as in carbuncle), and even by an extreme amount 
of congestion.* The occurrence of gangrene is favored by extreme 
weakness of the heart, the great moving power of the circulation ; and 
the failure is most manifest in parts most remote from the heart, as 
in various structural diseases of the organ, in low fevers, and states of 
extreme exhaustion. It is favored by ossification or partial obstructions 
of the supplying arteries, which, although adequate to maintain the 
ordinary nutrition of the part, cannot dilate to supply the demand in- 
creased by any injury or irritation of the part. The agents, which cause 
gangrene by a directly destructive operation on the vital properties of the 
solids and fluids of the body, are various strong poisons, such as arsenic, 
sulphuretted hydrogen, the poison of the rattlesnake and other venomous 
animals, the poison of the plague, malignant scarlatina, small-pox and 
erysipelas, hospital gangrene, glanders, &c. 

475. An external part becoming gangrenous loses all feeling and 
other vital properties; its color becomes livid, or leaden, greenish, or 
almost black, the cuticle rises in blisters on it, and begins to exhale an 
offensive odor. The rapidity of this change will depend much on the 
moisture and warmth derived from the adjoining living parts; in dry 
gangrene, the dead portion becoming horny and black instead of putre- 
fying. For the converse reason, in internal parts the progress of decom- 
position is more rapid. The putrid matter affects the living body (like 
many animal poisons) as a local irritant, and a general sedative or de- 
pressing agent: and the symptoms will vary much as one or the other 
of these two operations predominates. 

In persons of robust constitution, active vascular system (§§ 112, 120), 
and good blood (§ 195), a dead part arouses active inflammation and 
effusion of lymph in the surrounding living parts, which may protect the 
system more or less completely from the infection of the dead matter. 
In such cases, although gangrene be present, the predominant symptoms 
may be those of inflammation and inflammatory fever. But living parts, 
with all their activity, cannot long withstand the pernicious influence of 
dead matter; so that if this matter be not soon thrown off in the form of 
a slough (§ 473), or liquefied in the inflammatory exudations poured out, 
the system becomes infected, and suffers from its poisoning and pros- 
trating operation. This will happen more surely and early, where the 
dead part is in the interior of the body, of great extent, surrounded by 
vascular texture, and with its decomposition promoted by the warmth 
and moisture. In subjects of weak constitution, feeble vascular system, 
and blood defective in plastic matter (§ 196), the irritation of dead mat- 
ter may fail to excite a protective (adhesive or plastic) inflammation, and 
the putrid or typhoid symptoms then show themselves earlier, and prove 
more speedily fatal. These symptoms are, — increasing feebleness and 

* Two cases of gangrene of the lung which have occurred in my practice seemed refera- 
ble to this cause. 



INFLAMMATION — STHENIC — ASTHENIC ACUTE. 



241 



frequency of the pulse, reduction of the fever, collapse and extreme pal- 
lidity of the countenance, cold sweats, brown, dry, or clammy foul 
tongue, low delirium, or restlessness and agitation of manner, hiccup, 
fetid diarrhoea, urine very offensive or suppressed, coma or syncope, and 
death. In external parts, or those which communicate with the surface, 
the putrid odor of the gangrenous part becomes a distinguishing physical 
sign; in gangrene of the lungs it is communicated to the expectora- 
tion and breath; in other cases, the whole body exhales a fetid odor. 

The supervention of gangrene sometimes terminates the pain and 
other severe symptoms of the preceding inflammation, and thus induces 
a false calm ; but they are often replaced by distressing symptoms of 
nervous irritation, which subside only with the collapse of death. 

476. In concluding this account of the results or terminations of in- 
flammation, I must repeat what was said at the beginning (445), that 
they rarely occur quite separately one from another, and in many in- 
stances they are all combined in different portions of an inflamed organ 
or texture. Thus resolution is always attended with some amount of 
effusion: lymph often has the color, opacity, and much of the micro- 
scopic character of pus; suppuration is almost always preceded and 
generally accompanied by the effusion of some lymph; and often ab- 
scesses are attended with gangrene and sloughing of parts; and these 
combinations are further illustrated by the terms, purulent lymph, flaky 
pus, sloughing ulcer, gangrenous abscess, &c, which pathologists are 
obliged to employ to describe what they meet with. 

VARIETIES OF INFLAMMATION. 

Inflammation may vary in consequence of the predominance or defect 
of some of its elements or results, or from its combination with some of 
the other elements of disease previously considered. Or inflammation 
may derive a peculiar character from the nature of its exciting cause, 
which is exemplified in what are called specific inflammations. The fol- 
lowing varieties demand a brief notice: — sthenic and asthenic; acute, 
subacute, and chronic; congestive ; phlegmonous ; erysipelatous ; pellicular 
or diphtheritic; hcemorrhagic ; and scrofulous. Of the specific inflam- 
mations, the gouty and rheumatic, syphilitic and gonorrheal, will be 
merely alluded to. 

477. The varieties of inflammation, termed sthenic and asthenic, cor- 
respond with the parallel varieties of plethora (§ 279), hemorrhage (§ 360), 
and flux (§ 393), and are referable to a difference in the strength and 
irritability of the heart and arteries (§§ 110, 120, &c.) Thus sthenic 
inflammation is marked by a strong hard pulse, high fever (§ 442), very 
fibrinous blood (§§ 208, 438), a full and active development of the chief 
symptoms of inflammation (§429), and a tendency generally to the more 
plastic products (§ 450). Patients affected with sthenic inflammation, 
require and bear a greater amount of antiphlogistic treatment; and in 
them, if used in time, it is commonly most successful, for sthenic inflam- 
mation occurs in those of the most robust constitution, in whom the 
effects of disease are most readily shaken off*. 

16 



242 



PROXIMATE ELEMENTS OF DISEASE. 



Asthenic inflammation occurs in persons, the tone and real strength 
of whose vascular system is low (§§ 116, 123), and their blood (generally 
speaking) poor (§ 207). The pulse is not always affected; when it is 
affected, it is in frequency, more than in strength or firmness ; the fever, 
if there be any, is of a slight, remittent, or low character (§ 442, &c). 
The products are either scanty, or of a cacoplastic or aplastic character 
(§ 451); or the effusion may be chiefly watery, the inflammation differ- 
ing little from flux and dropsy. 

478. The terms acute, subacute, and chronic, applied to inflammation, 
properly relate to its duration ; but they are often used in the sense which 
I have given to sthenic and asthenic. Acute inflammation may be, and 
commonly is, sthenic; but it is by no means always so: its distinctive 
character is, that it tends to a speedy termination of some kind or other. 
It may end in resolution, effusion, suppuration, or gangrene, in a period 
varying from a few days to three weeks. An inflammation lasting above 
the latter period is subacute, and if protracted beyond six weeks is pro- 
perly called chronic. Very commonly, inflammation is acute, because 
it is severe or sthenic, its intensity leading to a speedy result: but asthe- 
nic inflammation is often also short in its duration; whilst chronic inflam- 
mation sometimes presents a good deal of the sthenic character (§ 477). 
Acute inflammation, when at all extensive, is attended with considerable 
fever and constitutional disorder. With subacute inflammation, the 
fever is less, and may even be absent. In chronic inflammation there is 
rarely fever; when present, it is of a remittent or hectic kind(§§ 444, 
471). 

The products of acute inflammation are commonly so copious as to 
be distinct in their character, being coagulable lymph, pus, inflammatory 
mucus, &c. In subacute inflammation they are often intermediate, such 
as purulent lymph, curdy matter, and tubercle in some of its forms. As 
with asthenic inflammation, the more they are in quantity, the less likely 
are they to become well organized. 

479. Chronic inflammation may originate in the acute or subacute 
forms, the vascular obstruction and excitement persisting in the part, 
even after some of the results (§ 445, formerly called terminations) of 
inflammation have been produced. Its general character is asthenic ; 
but there may be considerable determination of blood and local excite- 
ment. Its effect in disturbing the functions, both of the part which is 
its seat, and of other parts, is much less prominent than that of acute 
inflammation; but its duration causes a more serious and lasting altera- 
tion of structure. The matter effused by serous membranes in chronic 
inflammation is always either cacoplastic or aplastic ; hence, dense and 
contractile adhesions, or patches of fibrocellular or semicartilaginous 
matter, cirrhosis, gray miliary tubercle, curdy and yellow tuberculous 
matter, may be numbered among the common products of chronic inflam- 
mation. Mucous membranes discharge muco-purulent, or curdy matter, 
and the more complex membranes of this class, become thickened and 
may ulcerate. Submucous textures become the seat of deposit, which, 
in becoming organized, often contracts, forming strictures in mucous 
passages. These strictures, by obstructing the passages, may lead to 
dilatations above them. In. glands, and other complex textures, chronic 



INFLAMMATION CHRONIC — CONGESTIVE. 



243 



inflammation causes consolidation and induration, which often afterwards 
contracts and effects the obliteration of the connected texture, as in the 
changes in the lungs, liver, and kidney, inaptly described under the 
name cirrhosis.* Sometimes the indurated parts, from the pressure on 
their vessels, become softened (§ 463), as in softening of the brain, or 
undergo a process of irregular suppuration and ulceration, as in the 
excavation of the lungs after chronic inflammation. As we noticed of 
congestion (§ 311), so it may be added of chronic inflammation, that 
the hypertrophy or excessive deposit of nutritive material is irregular, 
more in some textures than in others, generally abounding most in the 
interstitial cellular or filamentous tissue, which, by its hypertrophy, 
presses on the vessels and other textures, and often causes their atrophy 
and partial obliteration. Chronic inflammation in the cartilages ends in 
caries and ossification ; in the bones also, it causes caries or exostosis, 
just as in the skin and other compound textures it leads to induration 
as well as ulceration. The production of these apparently opposite 
results by the same process, inflammation, is not paradoxical, when we 
bear in mind the compound character of this process, and the variations 
arising from different proportions of its elements and products. Chronic 
inflammation exhibits these opposite results the more strikingly, because 
its effects are accumulated by its long duration ; the hypertrophy arising 
from one of its elements (determination of blood) increases in the imme- 
diate neighborhood of atrophy and ulceration, the results of another of 
its elements (vascular obstruction). 

480. Congestive inflammation is that in which the accumulation and 
retardation of the blood in the vessels of the affected part predominate 
over the determination of blood. Hence it is commonly asthenic in its 
character (§ 477), and generally originates from causes producing con- 
gestion in the first instance (§ 403), the reaction which converts this into 
inflammation being imperfect or partial. Its symptoms are less promi- 
nent than those of more active inflammation, and partake more of the 
character of those of congestion. Thus there may be little pain, heat, 
fever, and other signs of irritation or increased action; but the redness 
(where visible) is more marked and deeper than usual, and if the organ 
be very vascular, (as the liver, lungs, and kidneys,) the swelling may 
be considerable. Congestive inflammation is usually subacute or chronic, 
not tending to speedy results; but a kind of flux or dropsy may occur 
early, as from congestion (§ 375). So, too, the solid or nutritive effusion 
is generally cacoplastic, like that of congestion (§ 311); hence the con- 
solidations or indurations arising from it are often of a dense indolent 
kind, tending to contract, or to degenerate still further into aplastic mat- 
ter (tubercle). The inflammation of the lung supervening on disease 
of the heart, on bronchitis, and asphyxia, is generally congestive; and 
so is inflammation of the liver from any cause. 

* Mr. Gulliver describes the consolidation of chronic pneumonia as characterized by " dark 
exudation corpuscles," as pale exudation corpuscles are the chief objects in red or acute 
hepatization. It appears, however, that these corpuscles are not dark from color, but merely 
from opacity, as pus and tubercle are; and they bear a further resemblance to this last pro- 
duct, in their irregularity in shape, size, and composition, being of various shapes, and con- 
sisting of molecules, generally without a nucleus, and often without envelop. — Notes to Dr. 
Boyd's "Vital Statistics^ Edin. Med. and Surg. Jour., July, 1843. 



244 



PROXIMATE ELEMENTS OF DISEASE. 



481. Phlegmonous inflammation is exemplified in the phlegmon, fu- 
runcle, or boil of the integuments. Its chief character consists in its 
being abruptly circumscribed by an effusion of solid lymph, which brings 
the inflammation to a termination, either by suppuration, or by slow sub- 
sidence, as in the case of blind boils. A highly fibrinous condition of 
the blood (§ 195) contributes to render inflammation phlegmonous; but 
this form of inflammation is that commonly exhibited by cellular and 
parenchymatous textures. The type of phlegmonous inflammation is 
usually sthenic (§ 477); and even where it advances to suppuration or 
sloughing, it defends the body against the noxious influence of the pus 
and dead matter. Hence the fever is more inflammatory (§ 442), and 
the local pain, irritation, and heat, are considerable. 

482. Erythematic or erysipelatous inflammation is contrasted with 
phlegmonous, in its tendency to spread, not being attended with the 
effusion of plastic lymph. In its severe forms, it is accompanied by much 
redness, pain, or smarting, heat, and swelling; the effusion is chiefly 
serous, or sero-purulent, and often raises the cuticle in blisters. In its 
worst kinds, it terminates in diffused suppuration, sloughing or gangrene. 
The fever is also of a lower type (§443) than in phlegmonous inflamma- 
tion; being attended by great weakness, disorder of the secretions, foul- 
ness or dryness of the tongue, with delirium, and confusion or dullness 
of the senses; and in the worst cases, the fever is typhoid, with stupor, 
muttering delirium, dry brown tongue, sordes on the teeth and lips, slight 
convulsive startings of the limbs, (subsultus tendinum,) fetid or sup- 
pressed excretions, and sinking. 

These adynamic or typhoid symptoms show the presence of something 
more than a form of inflammation, and that something must be considered 
to be a poison. It is probable that this poison sometimes originates in 
infection (§ 93); for persons in the same room, or who have had much 
communication with a patient with erysipelas, have been more frequently 
attacked than others ; but it is also pretty certain that bad ventilation, 
and a crowded, uncleansed state of surgical patients, are capable at any 
time of rendering common inflammation erysipelatous; and this effect 
is much promoted by unknown epidemic conditions of the atmosphere 
(§ 89). The most probable hypothesis which we can form of this matter 
is, that under certain circumstances, the products of inflammation, be- 
come (as we know they sometimes do, § 470) poisonous; and capable 
of acting (as many animal poisons do) as local irritants and general 
sedatives or depriments ; that they then modify the character of the in- 
flammation, and depress the whole vital powers (as we have found pus 
and gangrenous matter do, §§ 471, 475); and that their effects, and the 
general and local reaction againt them (§ 17), lead to the various degrees 
and forms which we find erysipelatous inflammation and its accompany- 
ing fever present. The same morbid matter, being transferred by any 
of the three modes of infection (§ 94) to other persons, may induce ery- 
sipelas in previously existing inflammation, or if strong enough, may 
develop it anew in the body. The fact that patients often sicken with 
fever (rigors, vomiting, headache, quick pulse, delirium, &c), before the 
erysipelatous inflammation appears, is a sufficient proof that the poison 
acts on the constitution as well as on a part; and the fact that weakly 



INFLAMMATION — VARIETIES — PELLICULAR. 



245 



persons, and those with previous structural disease, (especially of the 
kidneys,) chiefly suffer from the worst effects of erysipelas, shows the 
essentially depressing operation of the poison. In several cases of the 
worst forms of erysipelas, I have found pus globules in considerable num- 
bers in the blood of parts remote from the affected textures ; which cor- 
responds with the observations of Mr. Gulliver (§ 462). This might sug- 
gest that pus is the poisonous matter; but although it is highly probable 
that these pus globules do partake of the septic tendency formerly noticed 
as belonging to foul kinds of matter (§§ 462, 3), yet it is likely that the 
noxious matter occurs and spreads in a more subtle form, in solution or 
even in vapor, as shown by the pernicious properties of the liquor puris, 
and its fetid odor(§§ 470, 472). 

Some asthenic inflammations of mucous and serous membranes and 
internal organs exhibit many of the constitutional effects of the worst 
forms of erysipelas; they sometimes prevail when it is epidemic, and may 
be traced to the same infection. This may be said especially of puerperal 
metritis and peritonitis, erysipelatous tonsillitis and laryngitis, and sup- 
purative phlebitis. 

483. Pellicular or diphtheritic inflammation of mucous membranes has 
some affinity to the erysipelatous, being diffused and spreading, generally 
asthenic, and accompanied with a low kind of fever. It is attended 
with more soreness than pain, little swelling, and a deep redness, which 
is early obscured by the characteristic film of grayish or dirty white albu- 
minous matter, which is exuded on the inflamed surface. Patches of 
this kind often occur on the tonsils in sore throat, and have been com- 
monly mistaken for sloughs. In certain epidemics, often connected 
with scarlatina, a diphtheritic inflammation affects the whole throat, and 
sometimes extends to the trachea and air-tubes, the mouth, the gullet, 
and to more or less of the alimentary canal. The films of lymph thus 
effused are often fetid, apparently from incipient decomposition, which 
is promoted by their exposure to air and moisture in the throat and air- 
passages. As in the case of diffused suppuration and gangrene, this 
result of inflammation thus tending to putrefy is at once a sign of the 
low condition of the vital powers, and a cause of their further depression. 

The exudation of lymph instead of mere mucus or purulent mucus as 
usual, I am disposed to refer to the inflammation affecting the submucous 
cellular tissue, and being at the same time diffused like erysipelatous 
inflammation. Deep-seated inflammation of a more sthenic character 
is circumscribed by the effusion causing a thickening of the membrane, 
as in laryngitis; but the matter effused by diphtheritis, although fibrinous, 
is thin enough to transude through the mucous membrane on the surface of 
which it concretes. The thinness of the mucous membrane of the air- 
passages in children facilitates the transudation in their deep-seated in- 
flammations: hence, at an early age, all such inflammations may cause 
an effusion of fibrinous matter, as we find exemplified in croup. So, 
too, the extreme tenuity of the mucous lining of the smaller divisions of 
the air-tubes makes the exudation of fibrinous matter a common result in 
pneumonia and some kinds of capillary bronchitis. This is exemplified 
in the ramiform moulds of the bronchial tubes sometimes expectorated. 
Similar skin-like exudations are sometimes passed from the intestines after 



246 



PROXIMATE ELEMENTS OF DISEASE. 



the irritation of calomel or other strong purgative, and in some cases 
without any such irritation. I have had several patients under my care, 
who from time to time pass from the bowels a quantity of shreds like 
white kid leather, without any symptoms of active inflammation: con- 
gestion seems to be a chief cause in these cases (§ 308). 

In the mouth and throat, various asthenic inflammations seem to be 
capable of causing a fibrinous exudation, as that from mercurial action, 
and that in the aphthous mouth and throat of adults, which occurs towards 
the fatal termination of various chronic diseases. Recent microscopic 
observations have proved that in some of such cases at least, the 
film consists chiefly of a confervoid vegetable. I ascertained this to be 
the case with regard to a remarkably white curdy coating on the fauces 
and gums of an aged female now (July 1847) under my care in the hos- 
pital : the matter was almost totally composed of the jointed tubes, and 
brilliant sporules and granules of the parasitic growth. The aphthae of 
children are somewhat different, being vesicular elevations of the epithe- 
lium, with or without an albuminous film underneath. 

484. Hemorrhagic inflammation is entitled to be considered as a dis- 
tinct variety. In most inflammations, there are slight extravasations of 
blood; but sometimes there is so much coloring matter in the inflamed 
texture and in the products effused, that it may be difficult at first to say 
from the appearance whether the disease is a hemorrhage or an inflam- 
mation. These inflammations I have found to be asthenic; often the 
subjects were scorbutic, or affected with purpura; and, as I have stated 
with regard to the latter disease (§ 358), there has been distinct evidence 
of imperfect action of the liver and kidneys. Thus I have several times 
met with hemorrhagic pleurisy and pericarditis in* conjunction with 
cirrhosis of the liver, and Bright's disease of the kidney. An altered 
condition of the coloring matter (§ 186) is perhaps more concerned in 
causingthis result than a deficiency of the fibrin, to which it is commonly 
ascribed : in fact, this is found more or less in excess as in other inflam- 
mations, but very probably it may be defective in its usual contractile 
property (§ 203). 

485. Scrofulous inflammation is decidedly asthenic, and exhibits 
many deviations from the common form of inflammation. It may be 
well exemplified in the lymphatic glands, one of its most common seats, 
and within the reach of direct observation. These glands, in common 
inflammation, become very painful and hot, as well as swollen, and the 
inflammation tends soon either to resolution or to suppuration. In scro- 
fulous inflammation, on the other hand, lymphatic glands swell to a 
great size; and often the deep redness extends to the surface, but with 
little pain or heat; and the swelling remains for a very long period without 
either resolution or suppuration, and little influenced by antiphlogistic 
remedies. Sometimes it seems to suppurate, so that the swelling becomes 
distinctly fluctuating, and very red, as if ready to open ; but afterwards 
the skin becomes wrinkled, and the swelling subsides. When it does 
burst, or is opened, the pus is serous and curdy, or mixed with matter 
of a soft cheesy consistence, (soft tuberculous matter;) and the abscess 
thus opened leaves a deep ulcer with a narrow orifice (fistula), which is 
indisposed to heal. The microscopic characters of scrofulous matter 



INFLAMMATION — VARIETIES — SCROFULOUS. 



247 



are a paucity and irregular form of the pus globules and a great pre- 
dominance of granular matter, loose or coherent in clots, and oil globules 
in considerable numbers. These characters at once explain both the 
aplastic and the indolent properties of the matter; being destitute of 
the organizability of fibrin, and of the cell developing and endosmotic 
attributes of pus (§ 461). In proportion as it gets older, as in cold 
abscesses, the pus globules become collapsed, and the liquid partly ab- 
sorbed, the matter acquires a cheesy or putty-like consistence, and in 
time undergoes a further change into fatty matter and phosphate of lime. 
The kind of inflammation from which this has originated occurs in per- 
sons of what is called the scrofulous diathesis or constitution. 

The scrofulous diathesis is merely a term employed to designate a 
state of the body, in which scrofulous inflammation and malnutrition are 
apt to occur. It has been generally stated that this diathesis has certain 
outward marks, by which its existence may be recognized, independently 
of the actual occurrence of disease. Thus, a relaxed state of the mus- 
cles, a soft transparent skin, a fair or pale complexion, with partial 
patches of a peculiar pink or purplish redness; a pearly whiteness of the 
eye and teeth ; tumid upper lip ; fair or reddish hair ; large and weak 
joints, precocity of intellect, and some other signs, have been described 
as characteristic of the scrofulous diathesis. But such marks may oc- 
cur without any manifestation of scrofulous disease ; and still more fre- 
quently, scrofulous disease is induced in persons quite destitute of these 
characters. 

More constant concomitants of the scrofulous disposition (although 
they sometimes occur without scrofula) are, various signs of weak circu- 
lation and imperfect nutrition, such as cold extremities ; weak, but easily 
accelerated pulse; small development of muscles; uncertain digestion 
and irregular excretion ; slow or defective healing of wounds. The cir- 
cumstances which most favor the production of the scrofulous diathesis, 
are also causes of a weakening kind, especially when these are long- 
continued, such as poor or insufficient nourishment, especially in child- 
hood or youth; cold and damp situations, or defective clothing; long 
confinement in close, ill-ventilated habitations; long-continued illness, 
especially from eruptive or typhoid fevers ; and prolonged and aggra- 
vated disorders of the digestive organs. Scrofula is also, in a marked 
degree, an hereditary affection (§ 36) ; and mere feebleness of constitu- 
tion in parents, whether original or from disease, or from excesses, or from 
age, often develops a disposition to scrofula in children. 

In persons of the diathesis now noticed, inflammation frequently runs 
a course, and leads to results different from those of inflammation in a 
healthy subject. Commonly, the inflammation is more asthenic (§ 477); 
often it is more subacute or chronic (§ 479) than usual ; but in all cases, 
its solid products are not euplastic (§ 450), as in healthy persons; and 
may be either cacoplastic (§ 452) or aplastic (§ 453), according to the 
prevalence of the scrofulous constitution, the texture affected, and the 
quantity of the inflammatory product thrown out. Where the scrofulous 
diathesis is most developed — where the texture inflamed is an internal 
one, not freely discharging externally — and where the product of inflam- 
mation is most copious — there the deposit will be most aplastic, consist- 



248 



PROXIMATE ELEMENTS OF DISEASE. 



ing of scrofulous pus or yellow tubercle, devoid of regular structure, and 
wholly insusceptible of organization ; and being not fit for absorption, 
it operates as a foreign body, irritating, obstructing and compressing the 
adjoining parts, in various ways detrimental to their functions and struc- 
ture. Thus arise tuberculous or scrofulous deposits and abscesses in 
lymphatic glands, in bones, cartilages, and in the connected cellular 
textures, tuberculous infiltrations in the lungs, and deposits in serous 
cavities. Where the scrofulous diathesis is less pronounced, and the 
inflammatory effusion less copious and more gradual, the result may be 
a cacoplastic product, susceptible of only a low organization ; as gray, 
miliary and tough yellow tubercle; cirrhosis, atheroma of arteries, fibro- 
cartilage, and other degraded living solids. These have been already 
noticed (§§ 453, 454), and will again come under consideration as pro- 
ducts of altered nutrition. The aplastic tendency of inflammation in 
scrofulous subjects is sometimes manifest in other forms in different 
textures. Synovial membranes of joints are softened into a brownish 
pulp (Brodie) ; articular cartilages and the cornea ulcerate, from absorp- 
tion predominating over nutrition (§ 466) ; the integuments of the face 
and other parts inflame in small cutaneous tumors or tubercles, which 
ulcerate, and for w T ant of plastic material, the ulcers are phagedenic, 
spreading and destroying the nose or adjacent parts, as in lupus. 

It seems, then, that the most constant peculiarity of scrofulous inflam- 
mation is, that it degrades or arrests nutrition by supplying a material 
in a condition little or not at all susceptible of organization. This leads 
us to inquire what is the condition of the blood in scrofula ; and we are 
answered by the interesting fact ascertained by Andral and Gavarret 
before mentioned (§ 454), that there is an excess of fibrin (§ 195), but 
a deficiency of red particles (§ 185). The fibrin is, however, defective 
in that finely fibrillated structure indicative of vitality ; and this seems 
to favor the hypothesis that the red particles are concerned in preparing 
this plasma (§ 210); where they are deficient, it is ill prepared. 

486. Gouty and rheumatic inflammations have already been noticed 
in relation to their specific cause, a morbid matter in the blood or in the 
textures (§§ 251, 254); and some of the peculiar characters of the in- 
flammation were then adverted to (§ 385). It is highly probable that 
the peculiarities of many other inflammations, especially of the skin, 
such as urticaria, eczema, psoriasis, and erythema, may be referred to a 
similar cause, a particular matter in the blood irritating the parts through 
w 7 hich it circulates (§ 402). 

487. The poisons of gonorrhoea and syphilis excite inflammations still 
more peculiar in their phenomena and course. Gonorrhceal inflammation 
chiefly affects the genito-urinary passages and the conjunctiva. It is 
generally acute, and results in the secretion of an opaque sulphur-colored 
pus which is capable of propagating the disease. Sometimes it affects 
the testicle also with acute inflammation, and the joints with more chronic, 
constituting gonorrhceal rheumatism. 

Syphilitic inflammation exhibits great varieties in site and effects. 
Locally, the syphilitic poison may excite on any thin-skinned surface a 
papula, or small tubercle, which, ulcerating, forms a chancre. As the 
matter is absorbed from this, it causes inflammation with great pain and 



CONSTITUENTS OF INFLAMMATION. 



249 



swelling of the neighboring lymphatic glands (bubo), which may sup- 
purate. These are primary inflammations, and of an acute character. 
When absorbed into the system, it may excite secondary inflammations; 
sore throat, generally asthenic, and tending to ulcerate; and a great 
variety of inflammations of the skin, which vary greatly in their type as 
well as in their character, according to the vigor, &c, of the subject. 
They often leave a peculiar lurid or copper-colored stain in the under 
layer of the epidermis, which obviously arises from an extravasation of 
some coloring matter of the blood, and probably implies a change in it. 
The periosteum and bones are also often attacked with syphilitic inflam- 
mation; and painful nodes, exostoses, suppuration, and caries, may 
result. The iris is sometimes attacked with acute inflammation and 
effusion of lymph, which may endanger sight if not reduced. 



TREATMENT OF INFLAMMATION. 

488. We have found inflammation to be an essentially complicated 
process, composed of several constant elements, to which are frequently 
added others, which further increase the complexity of the disease. A 
proper knowledge of these elements, and of the means which best re- 
move or counteract them, separately and in combination, will form the 
best guide to the rational treatment of inflammation, and will supply a 
safe clue through the confused and paradoxical assemblage of agents 
which experience has proved to be antiphlogistic remedies. As we have 
not time to discuss in full detail the elements and results of inflammation 
with regard to treatment, it will be useful to enumerate these elements 
and results, with, references to the text, which more fully explains them, 
and then to represent in a tabular view the remedies that may be opposed 
to these elements and results respectively; various combinations of which 
remedies constitute the antiphlogistic treatment. 



From operation 
of 

exciting cause 



"S 



Local elements 
of inflammation, « 
(essential.) 



489. Constituents of Inflammation. 

Congestion (§ 403, 407), 
or 

Nervous and vascular irritation (§ 402, 408). 

Determination of blood towards the affected part (§§ 409, 419). 

Obstruction of the vessels most affected (§§ 410, 419) ; by atonic enlarge- 
ment of the capillaries (§ 414) ; by production and adhesion of white 
corpuscles in the vessels (§ 415). 

Distention of arteries and capillaries before the obstruction (§ 420), 
causing increased effusion (§ 423) of serum, lymph, pus, &c. (§ 427). 

Emptiness of veins beyond the obstruction (§ 427), causing increased 
absorption (§ 467), hence softening, &c. 

Impeded or arrested circulation at the obstruction (§ 418), causing a 
reduction or abolition of vital properties (§ 273), hence the death of 
the part, and its removal by ulceration (§ 466) and suppuration (§ 427), 
or its decomposition by gangrene (§ 473). 

Increased circulation of blood around the obstruction (§ 410), causing 
exaltation of vital properties (§§ 421, 333); hence spasm (§ 113), 
pain (§ 135), sympathetic irritations (§ 149), increased secretion (§ 
159), &c. 



250 



PROXIMATE ELEMENTS OF DISEASE. 



' Extension.of the excitement to the heart and arteries (§ 440), causing 
inflammatory fever. 
Change in the whole blood, by increase of fibrin from the inflamed part 
Constitutional (§ 438), and by diminution of the excretions in the inflammatory 

effects of J fever (§441). 
inflammation, 1 Exhaustion ensuing after the excessive excitement (§ 116), or the effu- 
(not essential.) sions of inflammation (§§ 459, 470). 

Depression, sometimes with partial irritation, from the presence of pus, 
or gangrenous matter in the blood (§§ 470,475); and retention of 
excrementitious matter (§ 443). 



490. TABULAR VIEW OF THE CHIEF ELEMENTS OF INFLAMMATORY DISEASE 

AND THEIR REMEDIES. 



CONSTITUENTS OF INFLAMMATION. 

1. Congestion 

2. Irritation of nerves 

3. — of vessels 

4. Determination to the part 

5. Obstruction in the part : 

— by atonic enlargement 

6. — by adhesion of corpuscles 

7. Distention of vessels . 

8. Effusions ..... 



9. Increased absorption . . . 

10. Impeded circulation in the part . 

11. Increased circulation around 



12. Excitement of the heart 



13. — of the arteries generally 

14. Change of the blood : 

— by increase of fibrin 

15. — by diminution of the excretions 

16. Exhaustion ..... 

17. Depression from poison 

18. Effused products of inflammation 



ANTIPHLOGISTIC REMEDIES. 

(Astringents; stimulants; evacuants; (§ 
I 315 et seq.) ..... 
Narcotics; counter-irritants (§§ 137, 155) 
( Sedatives ; derivatives; evacuants; (§ 342 
( et seq.~) ...... 

( Cold and other sedatives ; derivatives ; 
I evacuants 

Remedies for congestion (see above) . 
(Remedies not known; attenuants? (§ 
( 217); sedatives? (§ 416) 
(Counter-pressure; blood-letting; deriva- 

( tion(§319) 

(Evacuants; derivatives; operations; sor- 
( befacients? ..... 
f Direct remedies not known; stimulants; 

< diminishing atmospheric pressure on 
( the part . ... 

Moist heat and other stimulants . 
Remedies for determination, (see above) 

( General blood letting and other evacu- 

( ants; sedatives; (§ 115) 

{ General blood letting and other evacu 

< ants ; relaxants, (antimony, &c, § 122 ;) 
f salines? ..... 



Blood-letting and other evacuants; (§ 

214;) mercury; low diet 
Evacuants; alteratives (§ 172, et seq) 

Stimulants and tonics (§§ 119, 124) . 

Stimulants; antiseptics; evacuants; (§ 
260) 

Evacuants; attenuants; alteratives; sor- 
befacients ? stimulants ; pressure, and 
friction ...... 



491. My limits will not enable me to do more than offer brief com- 
ments on these principles of the treatment, and to exemplify the above 
table by the results of experience ; and it is an important corroboration 
of the truth of these principles that they expressly indicate the advantages 
of the various remedies which have been found effectual in the treatment 
of inflammation, they suggest the peculiar uses of them respectively, 



INFLAMMATION TREATMENT. 



251 



and they open us a path of inquiry in pursuit of others which are yet 
wanting. 

Remedies for incipient Inflammation. 

1. Congestion. — The efficacy of topical astringents and stimulants in 
the congestion preceding inflammation, is illustrated in the effect of a 
strong solution of nitrate of silver or sulphate of zinc in curing conjunc- 
tival ophthalmia, and of the same agents, or powdered alum, (Velpeau,) 
or capsicum gargles, in curing an incipient sore throat. But as with 
regard to congestion (§ 317), so still more in the congestive stage of in- 
flammation, if it be extensive, long established, or already complicated 
with determination of blood, they can never restore the lost tone, nor clear 
the obstruction of the vessels ; and if not they can operate only as irri- 
tants, and aggravate the inflammation; and it is especially under these 
circumstances that evacuants, derivatives, and even blood-letting, are 
more appropriate. The utility of these has been mentioned under the 
head of congestion (§ 318); but they may be more necessary in the con- 
gestive stage of inflammation, inasmuch as it tends to further, and worse 
results. A strong purgative and diaphoretic, if given early enough, may 
suffice to remove an incipient inflammation ; but if this inflammation be 
extensive, especially when the subject is plethoric, the proper remedy, 
even at this stage, is blood-letting, local or general, according to the 
situation and extent of the inflammation. 

492. — 2 and 3. Irritation of Nerves and Vessels. — The irritation of the 
nerves, w T hich we have found to constitute a part of the commencement 
of some inflammations (§ 403), is so closely followed by irritation of the 
vessels that their remedies are much the same. The efficacy of a large 
dose of opium in incipient inflammation exemplifies the utility of nar- 
cotics in subduing nervous irritation, and these remedies are the more 
indicated where pain, spasm, and other signs of excited nervous func- 
tion (§ 151) predominate. On the other hand, where heat and redness 
rather prevail, the disturbance is more in the vessels, and the more ap- 
propriate remedies are sedatives, such as cold and saturnine lotions to 
the part, and various evacuants and derivatives, which draw the blood 
away from the distended vessels. Counter-irritants or revulsives of the 
most speedy operation, such as heat, dry and moist mustard poultices, 
and other stimulating applications, near the affected part, seem to act 
both on the nerves and vessels, and are powerful means of subduing the 
irritation which leads to inflammation. In these applications the effect 
on nervous irritation is proportioned to the sensation which they produce, 
and where pain or other sign of nervous excitement predominates, a heat 
almost scalding or burning, or stimulating agents which cause severe 
smarting, are most effectual. On the other hand, w T here the vessels are 
excited, as evinced by heat and redness, (if visible,) counter-irritants or 
revulsives which act extensively rather than intensely are of more avail; 
such as a general or partial hot bath, or large poultice, or fomentation, 
made more stimulant by various additions.* On the same principle, 

* A great improvement in the means of fomenting parts with heat and moisture, with or 
without stimulating additions, is supplied in various water-proof fabrics, such as India rub- 



252 



PROXIMATE ELEMENTS OF DISEASE. 



purgatives and other evacuants continue to be indicated. Emollient 
and demulcent remedies, where they can be directly applied, often soothe 
an inflamed surface, both by promoting the natural secretion, by remov- 
ing irritating matter which may have caused the inflammation, and by 
reducing the acrimony of the morbid discharge, which is often acrid 
(§ 455). 

Remedies for established local Inflammation, 

493. — 4. Determination to the part. — This, with the following element, 
obstruction in the part, is only the further result of irritation of the ves- 
sels; but it is here named as a constituent of established inflammation. 
It is to be opposed by the same remedies as those just mentioned for vas- 
cular irritation, and formerly noticed as suitable for simple determination 
of blood (§ 342, et seq.), but as part of a disease which is more endur- 
ing and serious, the determination attending inflammation requires a 
fuller than usual application of these remedies. Of the sedatives appli- 
cable to this element, none is so effectual as cold, which we have found 
more than any other agent to promote the contraction of arteries (§ 120). 
It is thus that ice and cold lotions are very salutary in reducing active 
inflammation where they can be properly applied, as in external inflam- 
mation: in some internal inflammations the cold may be said to reach 
the interior, as by a bladder of ice to the head in meningitis, and by 
swallowing slowly small pieces of ice in gastritis. Cold will do harm 
instead of good in inflammation, either when it does not reach the enlarged 
arteries through which the determination takes place (§ 326), or when it 
is not sustained long enough to prevent the effects of reaction (§ 79), by 
which the arteries again become enlarged and determination is renewed. 
For these reasons, external cold applications are injurious in most internal 
inflammations, and if not steadiiy regulated, they may prove so in other 
cases likewise. 

Warmth and other derivants applied to parts more or less remote from 
the vessels which are the channels of determination are very serviceable 
aids in the treatment of this element: thus partial or general warm baths, 
hot poultices, &c, operate. Diaphoretics which equalize the circulation 
without stimulating, such as antimony, are also beneficial, by relaxing 
the cutaneous vessels generally, and thus deriving to the whole surface. 
So we have found (§ 345) purgatives and diuretics to operate as derivatives 
as well as evacuants ; and blood-letting was then stated to be the most 
effectual of all (§ 346). Change of posture, by elevating the part inflamed, 
should also be mentioned among the means which counteract determi- 
nation of blood. 

These different measures, which may suffice in simple determination, 
may be insufficient for that attending inflammation, chiefly because they 
cannot easily be sustained for a length of time. To produce a more 

ber cloth, oiled silk, or gutta percba rheet, being applied as a cover to prevent the escape of 
the heat and moisture. I have for many years adopted these auxiliaries with great advan- 
tage, especially where a prolonged effect is desired. The new India rubber epithems, called 
piliue and spongio-piliue, recently introduced into this country by a former pupil of mine, 
Mr. Markwick, answer the same purpose. 



INFLAMMATION — TREATMENT OF ITS CONSTITUENTS. 253 



permanent derivation or revulsion, as well as to act as counter-irritants, 
various agents are used to excite artificial inflammations, which counteract 
inflammatory disease by deriving and irritating in another direction. To 
this class belong blisters, mustard poultices, applications of tartar emetic, 
croton oil, strong ammonia, mineral acids, some essential oils, heat above 
120° Fahrenheit, &c. ; varying in the amount of inflammation which they 
excite according to the manner and duration of their application. As 
these fulfil several indications in inflammation they will again come under 
our notice. 

494. — 5 and 6. Obstruction in the part by atonic enlargement of the 
capillaries and by adhesion of the white corpuscles and accumulated im- 
paction of the red. — These are classed together, because they jointly 
continue to produce the partial obstruction which is characteristic of 
inflammation. The atonic enlargement of the capillaries may be thought 
to be included in the congestion before noticed ; but it stands here as a 
part of established inflammation, and therein different from mere conges- 
tion (§ 287). The remedies to be opposed to it are, however, the same as 
those mentioned under that head; but here they generally occupy a 
subordinate place, unless they fulfil other indications. There are, how- 
ever, a few cases in which the treatment for congestion, even by stimu- 
lants, proves effectual in curing inflammation. Catarrhal inflammations 
of mucous membranes are sometimes removed by a highly stimulant 
treatment with wine, spirits or ammonia. It is probable that the circula- 
tion is so much accelerated as to excite the dilated vessels to contract, 
and the obstruction is thus swept away. This treatment generally causes 
sweating and a deposit in the urine; but these seem to be as much the 
effects as the causes of the improvement, for sweating by other means is 
not so effectual. But this mode of treatment is hazardous, for it acts by 
increasing the flow of blood, and if this fail to remove the obstruction, it 
will surely aggravate the inflammation. 

But the most constant and important part of the obstruction of inflam- 
mation is due to the unusual formation and adhesion of the white cor- 
puscles in the inflamed vessels and the consequent accumulation of red 
particles entangled in them ; and inasmuch as it is this especially that 
establishes inflammation and is the cause of its most serious results, it 
would be most desirable to find some remedial influence to counteract it. 
Unfortunately, however, we are not acquainted with any direct means of 
preventing the formation and cohesion of these pale globules, or of dis- 
solving them when formed. As these globules appear to be formed in 
the blood-liquor, we should look for the desired remedies among the 
medicines which affect the blood; and it might be surmised that alkaline 
and other salts may possess this virtue. The efficacy of carbonate of 
potash as an antiphlogistic remedy has been much vaunted by Sarconi 
and other Italian writers ; but this is not confirmed by general experience. 
In fact, it appears, from the experiments of Mr. Blake (§ 214), that salts 
of potass, injected into the veins, promote the coagulation and stagnation 
of the blood instead of preventing them. Again, if the chemical view 
of their formation, which we have proposed, be correct (§ 417), it may 
be inferred that such means would be most effectual, as would interrupt 
the hyper-oxidation of the plasma, and as this depends on the determi- 



254 



PROXIMATE ELEMENTS OF DISEASE. 



nation of arterial blood to the part, we are led to see a new and impor- 
tant advantage accruing from the operation of depletion, derivation, 
sedatives, and other means calculated to reduce the force of the local and 
general circulation, and the richness of the blood which supplies the 
inflammatory material. Whether any deoxidizing agent could be made 
to assist towards the same end is a question worthy of investigation ; 
most materials of this description are objectionable on account of their 
stimulant or heating influence, as for example, alcohol and oils, and in a 
minor degree, sugar and starch. The deoxidizing agent should possess 
no such property, either before or after its own oxidation. Has the anti- 
phlogistic operation of antimony and mercury any relation to this mode 
of action? Their virtue is chiefly confined to their protoxides and proto- 
salts. Analogous preparations of other oxidizable metals which have no 
stimulant or injurious action, and sulphurets of metals and alkalies, have 
formerly enjoyed some repute as remedies in inflammation, and may 
deserve further trials. The most efficacious remedy that I know for cer- 
tain cutaneous inflammations, such as acne simplex in an excited state, 
is a weak solution of sulphuret of potash used as an outward application; 
and sulphuretted waters are acknowledged to be useful soothing agents 
in irritable states of the alimentary canal — both possibly owing to an 
operation of this kind. 

495. — 7. Distention of Vessels. — -This is another of the more charac- 
teristic constituents of inflammation, and has been explained to be the 
result of determination of blood into congested and obstructed vessels. 
In congestion, we formerly found distention sometimes to occur(§ 306); 
but there it is chiefly in the veins ; here it is in the small arteries, and all 
those parts of the capillaries that are on the arterial side of the obstruc- 
tion. This may account for the greater degree of distention, and the 
larger amount of effusion and other changes that result from it. But 
the peculiarity of the inflammatory distention and of the effusions which 
result from it, cannot be well understood without keeping in view that 
concentration or exaggeration of influence exerted by the red particles on 
the liquor sanguinis, when, on their accumulated and impacted masses, 
a strong current of arterial blood is continually impelled (§ 416). This 
view, too, suggests that the most effectual means of relieving it will be 
by speedily lessening either the determination of blood or the obstruction. 
The measures for reducing the determination must be now of the strongest 
kind, such as blood-letting and free derivation or evacuation ; because 
the arteries which are the seat of determination are closed at most of their 
capillary ends, and must be drawn upon either directly or through means 
which reduce the pressure in the arteries generally. Where, therefore, 
there is any considerable determination of blood, the distention which it 
causes will not be relieved without drawing blood either from the enlarged 
vessels themselves, or from other parts, in sufficient quantity to reduce 
the heart's action and the general arterial pressure. 

Other slighter means give some relief to the distention of the vessels 
in inflammation. External pressure, carefully equalized, can sometimes 
do this, as in the effect of well-applied bandages and strapping on 
wounds. Fluid pressure, as proposed by Dr. Arnott, by means of quick- 
silver, or the slack air-cushion under a bandage, might be still more 



INFLAMMATION — TREATMENT OF ITS CONSTITUENTS. 



255 



useful in various external inflammations, because its equality ensures its 
proper application. It is very probable that a part of the efficacy of 
poultices depends on the soft and uniform pressure which they produce 
on the inflamed vessels. But certainly poultices, fomentations, and other 
means of applying moist heat, relieve distention in part also by relaxing 
the solid fibres, and by promoting the exudation of the watery parts of 
the blood. 

496 — 8. The effusions from the vessels are the result of their continued 
impulsive distention. They may therefore be prevented or lessened by 
means which reduce this distention; but in severe cases of inflammation, 
effusion is the natural mode in which the vessels are relieved of their 
load ; and we have just mentioned that poultices and fomentations give 
relief by promoting this result. If the effusion is outwards, as from a 
mucous membrane, it may not be necessary to check it, except so far as 
it may interfere with the functions of the part ; but if it be too thick, 
alkaline medicines sometimes succeed in attenuating it, and thus promote 
its discharge ; whilst acids and various astringent remedies check it when 
it is too profuse ; but blisters and various evacuants should be combined 
with these last, otherwise the inflammation may be increased. This 
corresponds with what has been said of the treatment of sthenic fluxes 
(§ 393). When the effusion is in cellular texture, a serous cavity, or 
parenchyma, it may more seriously interfere with the functions of the 
part; and it may be more important to prevent, or restrain, or remove, 
the effusion. Thus, in the submucous cellular texture of the glottis, or 
in the serous membranes of the brain, a little effusion may prove fatal ; 
and in the lungs or pleura, effusions are injurious in proportion to their 
extent. Besides the measures directed against determination and vas- 
cular distention, it is doubtful that we possess means of restraining effu- 
sion. It is pretty certain that some other antiphlogistic remedies, espe- 
cially mercury and antimony, do diminish the effusions of inflammation, 
and promote their re-absorption ; but it is not clear that they do so in any 
more direct way than by reducing the local and general excitement, or 
by their evacuant effect. The expressions, " sorbefacient " and " excit- 
ing the absorbents," hypothetically ascribe to remedies the property of 
increasing absorption ; but nothing in physiology points out any direct 
mode in which absorption can be artificially increased. A free action 
of the excreting organs promotes absorption, by reducing the distention 
of the vascular system. Absorption is also promoted by a circulation 
that is free, without excitement or distention ;* and the return of the 
vessels to a healthy state is generally attended with more or less absorp- 
tion of the effusions. It is probable that blisters and other counter-irri- 
tant applications near the inflamed part promote absorption, not merely 

* In my Gulstonian Lectures (Med. Gaz , July, 1841), I adverted to the effect of a rapid 
current in promoting absorption. Mr. G. Robinson has since illustrated this effect by some 
experiments (Med. Gaz., May, 1843). Another influence which probably contributes, is the 
different density of the fluid within and without the vessels: that within is more dense and 
saline, and by the law of endosmosis, tends to attract the thinner fluid from without. This 
explains the greater readiness with which the thinner effusions are absorbed. Can we 
increase absorption by rendering the blood more saline than usual ? The thirst after taking 
salt food would seem referable to this cause ; and the beneficial influence of salines in 
inflammatory diseases may be partly due to this mode of operation. 



256 



PROXIMATE ELEMENTS OF DISEASE. 



as evacuants or derivants, but also by causing a rapid flow of blood 
through the adjoining vessels, which facilitates the endosmosis and 
removal of effused fluids. Hot fomentations and douches and stimulant 
frictions seem to operate in the same way. 

In various cases it is necessary to give vent to the accumulated effu- 
sion by surgical operation, as by incisions or acupunctures in erysipelas, 
opening abscesses, paracentesis in empyema, &c. This is chiefly neces- 
sary where the effused matter is purulent and little susceptible of absorp- 
tion, as well as noxious to the system; but sometimes the mere quantity 
or situation of the effusion, by endangering life, renders the resource of 
an operation necessary, as in acute laryngitis and some cases of pleurisy. 

497. — 9. Increased absorption is manifest in the processes of softening, 
ulceration, and suppuration. I have endeavored to explain how, in the 
midst of distended and effusing vessels, absorption is increased. The 
veins and lymphatics are free, and by the motion communicated to them 
from the current of the neighboring and anastomosing branches, they are 
ready to convey away all the fluids that can pass through their coats. 
(Gulstonian Lectures, 1841.) In fact, this is doubtless a provision for 
the removal of superfluous matter, old and new; but the process becomes 
injurious and destructive when it predominates over effusion, and exten- 
sively invades the living textures. But we have found reason to suppose 
that textures do not fall a prey to the softening or ulcerative process, 
unless their vitality is lowered and their nutrition impaired by a defective 
supply or quantity of blood (§ 466, 7) ; and that inflammation does produce 
these effects very differently in different cases. Sometimes local stimu- 
lants and general tonics check softening and ulceration • by improving 
the vitality and nourishment of the obstructed part ; but they may have 
the opposite effect if the circulation in the affected part is too much 
obstructed to admit of increase. Hence we find, in phagedenic ulcera- 
tions, stimulants sometimes check and sometimes aggravate the disease. 
The increased absorption which forms a part of ulceration might be 
arrested by diminishing atmospheric pressure on the part, as by applying 
a cupping-glass over a phagedenic ulcer; but such an expedient is rarely 
practicable. 

498. — 10. Impeded circulation in the part has been just adverted to as 
contributing, with increased absorption, to the processes of softening and 
ulceration ; but its greatest effect is manifest in gangrene, or the complete 
death of the part. In suppuration, also, the part dies, but it is removed 
by absorption, and replaced by pus, which makes its way to the exterior. 
Of the few agents that may be directed to restore or improve obstructed 
circulation, heat is the chief one to be named. Heat enlarges vessels, 
especially arteries (§ 120), and facilitates the passage of blood through 
them; and although, for this very reason, hurtful in sthenic inflammation 
and in parts where determination prevails, it is really very beneficial in 
the stages and forms of inflammation in which obstruction predominates 
and endangers the vitality of the part. Hence the utility of hot foment- 
ations or poultices in low forms, or advanced stages of external inflam- 
mation. In slight cases, frequent applications of heat and moisture may 
entirely remove the obstruction, restore the circulation, and thus the life 
of the part, although the inflammation may have already caused much 



TREATMENT OF INFLAMMATION WITH FEVER. 



257 



effusion. In other cases, heat does not remove the obstruction, and 
therefore does not maintain the life of the part; but by increasing the 
determination around it, it promotes its removal by suppuration, and it 
hastens and matures this process, which is the best by which a part, the 
circulation of which is obstructed, can be removed. In a similar way 
too, heat favors the effusion of lymph, which circumscribes the suppura- 
tion and prevents it from spreading or infecting the system. Lastly, in 
a similar way, heat and other stimulating applications promote the pro- 
cess of separation or sloughing of a gangrenous part (§ 475), the whole 
circulation and life of which have ceased. These latter effects of heat 
may often be promoted by medicines and food calculated to maintain the 
vigor of the general circulation. 

499. — 11. The increased circulation around the obstructed part is often 
that constituent of inflammation which causes the most prominent symp- 
toms, the greatest heat, pain, tenderness, and other marks of excited 
function being commonly dependent on it. We have already noticed 
determination as an element of inflammation in its early stage, and refer 
to that clause (4) for an account of the remedies with which it is to be 
combated. We now advert to determination to the neighboring vessels 
as a part of the extending irritation of inflammation, which often sym- 
pathetically excites the whole system into fever. The treatment, there- 
fore, partakes of the character of that suited for inflammation with fever. 

Treatment of Inflammation with Fever, 

500. The fever excited by inflammation consists chiefly of the items 
mentioned in the table ; but it will be more convenient to notice them 
here together. They are — (12) Excitement of the heart and (13) of the 
arteries ; (14) change in the blood by increase of fibrin, and (lb) by dimi- 
nution of the excretions. 

The addition of fever to inflammation very materially modifies the 
treatment. The disease then to be treated is not merely the inflamed 
part and a few other parts in sympathetic relation with it, but the whole 
vascular system, its blood and the secretions and functions which it sup- 
ports. In like manner, the treatment must now become general instead 
of local ; not because the local inflammation has lost its importance, but 
because it has now become a part of a general disease, w T hich sustains 
it with such an energy that local remedies become trivial, or even inju- 
rious. Thus, when inflammation is backed by febrile excitement of the 
heart and arteries, the stimulant and astringent antiphlogistic remedies 
(§ 491) irritate the distended vessels instead of making them contract. 
What can local blood-letting do when there is an excited force from be- 
hind impelling the blood to the inflamed part more rapidly than the oozing 
by local bleeding can relieve it ? Derivants also have little power when 
the tension of the whole vascular system is so much raised. Counter- 
irritants must even prove injurious, by adding another cause of excite- 
ment to the system. So, too, narcotics can have no control over fever 
once established, and may prove hurtful by exciting the nervous centres, 
and still further impairing the secretions (§ 166). Under these circum- 
stances, a more general remedy is wanted, which shall reduce the action 
17 



258 



PROXIMATE ELEMENTS OF DISEASE. 




of the heart and arteries, and diminish the inflammatory character of the 
blood. The first and most powerful remedy of this kind is general 
blood-letting; next come the stronger evacuants, antimony and mercury; 
and lowest in power are what are called refrigerants and direct sedatives. 
We shall briefly notice these antiphlogistic remedies. 

501. Blood-letting, if carried far enough, is sure to reduce the action 
of the heart ; for, as formerly explained, it may produce syncope (§ 70). 
A remarkable fact, first pointed out by Dr. Marshall Hall, is, that in in- 
flammatory disease, a much larger amount of blood may be drawn with- 
out producing syncope, than can be taken in health or in other diseases. 
The following is Dr. M. Hall's table of the results of his investigation 
of the tolerance of blood-letting in different diseases. The numbers re- 
present the mean quantity of blood which flows before incipient syncope 
in the sitting or erect posture : — 

I. Augmented Tolerance: — 

Congestion of the brain ..... 
Inflammation of serous membranes 
Inflammation of synovial membranes 
Inflammation of fibrous membranes 

Inflammation of the parenchyma of organs, (brain, lung, liver, 
mamma, &c.) ..... 

Inflammation of skin and mucous membranes (erysipelas, bron 
chitis, dysentery) ..... 

II. Healthy Tolerance : — 

This depends on the age, sex, strength, &c, and on the degree ) ~ 
of thickness of the parietes of the heart ; and is about $ 

III. Diminished Tolerance: — 

Fevers and eruptive fevers .... 5xi — xiv. 

Delirium tremens and puerperal delirium . . ^x — xii. 

Laceration or concussion of the brain . , ^ 

Accidents before the establishment of inflammation . > ^ viii — x. 

Intestinal irritation . . . . . ) 

Dyspepsia, chlorosis { ^ v "i. 

Cholera . . . . . . . 5jvj. 

The explanation of the increased tolerance of blood-letting in inflam- 
mation is, I apprehend, to be found in the increased excitability of the 
heart, and tonicity of the arteries, which maintain a sufficient force and 
tension to preserve the circulation, especially through the brain (§266), 
even when much blood is lost. In asthenic or atonic diseases, on the 
other hand, the arteries being lax, and ill-fitted to transmit the blood, a 
smaller loss is felt, and syncope may result. The variations between 
inflammations occupying different seats, must be referred to the heart's 
strength, and the arterial tone being less augmented in some than in 
others, and are, therefore, indications of more or less sthenic (§ 477) 
character of the inflammation. The quantity of blood in the whole sys- 
tem will affect the heart's action and arterial tension in a similar way; 
and no doubt the more stimulating quality of the blood may contribute 
to the same results. 

502. The object of blood-letting in inflammation is not merely to pro- 
duce syncope, or a temporary impression on the pulse, but a permanent 
reduction of the excitement of the heart and arteries; and this is to be 
effected in different modes of blood-letting under different circumstances. 



INFLAMMATION TREATMENT — BLOOD-LETTING. 



259 



Where the inflammation is quite recent, and the fever has not existed 
long, a moderate amount of blood, rapidly taken from a large orifice, or 
from two arms at once, or even from the jugular vein, will often be suffi- 
cient to reduce the fever and inflammation. The circulation is thus re- 
duced, perhaps, to syncope; and, relieved of the pressure and determin- 
ation of blood, the inflamed vessels soon recover their normal state, if 
not spontaneously, at least with the aid of some of the subsidiary anti- 
phlogistic measures. The benefit resulting from this mode of blood- 
letting in recent cases is sometimes very striking, and the cure is effected 
at a comparatively small expense of blood. 

503. But the case is different when an acute inflammation and fever 
have lasted for two or three days. There is then not merely excitement, 
but sundry changes in the inflamed part and in the blood, which keep 
up the excitement ; the inflammation has become established in the part, 
and the fever in the system ; and no brief impression on the circulation, 
however sudden and complete, can remove them. If in this state a 
patient be speedily bled to fainting, reaction will soon come on, and 
renew T the fever with increased intensity. Here, therefore, it is neces- 
sary to bleed more slowly and to draw more blood; and instead of pro- 
moting the occurrence of syncope by the erect or sitting posture, it is 
proper to keep the patient in an easy recumbent or reclining position, 
and to w r atch for the good effect of the bleeding in the softening of the 
pulse, or the relief of the pain or other distressing symptom. The actual 
occurrence of syncope is rather to be avoided, and may be prevented by- 
untying the arm as soon as the lips lose their color, or the patient com- 
plains of feeling sick or faint. Thus practised, blood-letting causes a 
more permanent reduction of the active elements of inflammation and 
fever, diminishes the exciting and too fibrinous condition of the blood, 
and although it cannot repair the changes already produced in the in- 
flamed part, it prevents their increase, and puts them in a condition 
favorable for the curative efforts of nature and the further operation of 
other antiphlogistic remedies. In the more severe and confirmed cases 
of inflammation it is often requisite to repeat the blood-letting again and 
again ; the indication for this being the return of incompressibility of the 
pulse, heat of skin, and a new T aggravation of the symptoms. In all such 
cases, the advantage of the gradual over the sudden mode of blood- 
letting is apparent, for where the reducing influence of this measure is 
longest sustained, it is least necessary to resort to it again. 

Another case in w T hich it is expedient to draw blood largely rather 
than suddenly, is where inflammation is combined with plethora. On 
the other hand, in anaemic subjects, the blood should be economized as 
much as possible ; the early depression from the loss of blood should be 
promoted by a posture favoring the occurrence of syncope, and might 
be sustained by the influence of antimony and other remedies. In some 
such cases the temporary withdrawing of a portion of blood from the 
heart and large vessels, by means of the process of hcemo stasis, may be 
very beneficial; by ligatures passed around one or more of the large 
limbs, more or less blood may be arrested in the limbs, and for the time 
withdrawn from the current of the circulation (§ 318); this expedient 



260 



PROXIMATE ELEMENTS OF DISEASE. 



is preferable to dry cupping, because it does not equally spoil the blood 
thus arrested. 

504. After the general excitement has been lowered or removed by 
general blood-letting, the local inflammation often has to be treated by 
topical blood-letting, which now is not only more efficacious in reducing 
the determination and distention of the inflamed part, but contributes to 
keep down the general excitement. In fact, local blood-letting, as by 
cupping or numerous leeches, may be made so extensive as to be tanta- 
mount to general blood-letting; and the cases in which it has most of 
this effect are those in which slow bleeding answers best. In either 
extreme of age, and in the feeble, local bleeding only is admissible. 
Local blood-letting is chiefly suitable for inflammations which are super- 
ficial and extended, as those of the pleura or peritoneum. It is of much 
less avail in pneumonia, cerebritis, and other inflammations of deep- 
seated or parenchymatous organs. 

505. Of other evacuants none are equal to purgatives, which are a 
great aid to blood-letting, and should be used in most cases of severe 
inflammation, uncomplicated with gastro-enteritic irritation. They operate 
on so large a surface that they affect the system, and their effect may 
be pushed to the extent of producing syncope; but such an extreme 
result is attended with much exhaustion, and their continued use may 
cause intestinal inflammation. The chief benefit arising from purgatives 
may be obtained from a few efficient doses at the commencement of the 
treatment. These aid the depressing effect of blood-letting, remove 
feculent matter, w T hich is often a source of irritation, and clear the intes- 
tinal canal for the operation of other medicines. The stronger and less 
heating purgatives are to be preferred, such as calomel, jalap, salts and 
senna, combined w T ith tartar-emetic or colchicum. A combination of 
several, which operate most on different parts of the canal, answers best. 

506. Of internal remedies against inflammation with fever, that which 
most resembles blood-letting in its effects, is tartarized antimony. It is 
far less sure in its operation, and its influence is not proportioned to the 
quantity ; yet under its use, especially if preceded by blood-letting, the 
pulse becomes less hard and frequent, the heat of skin is moderated, and 
sometimes perspiration ensues, w r hilst the local symptoms are generally 
more or less improved. Sometimes it causes vomiting, more rarely purg- 
ing; but its best antiphlogistic operation occurs where these effects do 
not ensue to interfere with a continuance of the medicine; and I have 
frequently found its utility most marked, when it did not cause even 
nausea or profuse diaphoresis. Tartarized antimony, and the milder 
preparation, James's powder, have been very long used in this country 
as febrifuge medicines; and Dr. Marryatt, who practised at Bristol in the 
last century, prescribed the former in large doses in the treatment of 
inflammation. The practice was since carried to a greater extent by 
Rasori, and other Italian physicians, who gave from 10 to 120 grains in 
twenty-four hours. Laennec adopted the use of the remedy in more 
moderate quantities, giving from one to four grains in some agreeable 
vehicle every second or third hour for six doses; then intermitting or 
-continuing it, according to circumstances. In pneumonia and rheuma- 
tism, he considered it the chief remedy. Most practitioners in this 



INFLAMMATION — TREATMENT ANTIMONY. 26 1 

country now consider tartar emetic a valuable aid in subduing inflamma- 
tion, chiefly to be used after blood-letting; or in slighter inflammations, 
where blood-letting is inexpedient. I rarely find it useful to raise the 
dose beyond two grains every three hours ; and in most cases one grain, 
half a grain, or even less, will suffice. The first doses sometimes 
cause vomiting; but this generally subsides when the doses are repeated, 
and may be prevented by giving the medicine in a mild neutral saline 
draught, with from five to ten minims of the diluted hydrocyanic acid in 
it. Antimony acts most satisfactorily in inflammations of vascular paren- 
chymata and complex membranes; such as the lungs, the testicles, the 
mammae, the air-passages, the cellular membrane and skin, and the 
joints. It is less effectual in inflammations of serous membranes, and 
would be unsafe in inflammatory affections of the intestinal canal. It 
is most beneficial in the early stages of inflammation, especially when 
attended with fever; and seems to have little effect on the products of 
inflammation. 

How antimony operates in reducing fever and inflammation is quite 
uncertain. Rasori considered it to be a direct sedative or contro- stimu- 
lant, diminishing the excitability of the vascular system, and thus neu- 
tralizing the inflammation. He supposed that the tolerance or power of 
the body to bear large doses of the remedy, entirely depends on the pre- 
sence of inflammation in the system; but, as Laennec has observed, this 
is not correct; for although patients suffering from inflammation are less 
easily nauseated than others, yet after the inflammation has been subdued, 
those quite convalescent have continued to take 12 or 18 grains daily 
without nausea, or even loss of appetite. Laennec first considered that 
the medicines act as a revulsive, by irritating the stomach; but this view 
being made by the Broussaians a ground of opposition to the use of the 
remedy, Laennec latterly represented it to act as a sorbefacient. It seems 
to me, that the most reasonable view 7 to take of its operation is, that it 
chiefly acts by diminishing the tonicity of the vascular system (§ 122). 
Small doses certainly relax the pulse and skin, and, where there is no 
fever, produce perspiration without stimulating. They also seem to 
increase the biliary and intestinal secretion. In inflammation and fever, 
larger doses are required to produce the same result; and as soon as 
the excessive arterial tension is relaxed, the chief part of the fever is 
removed (§ 441). By thus reducing the increased tonicity of the arteries, 
the circulation is equalized and quieted, and the determination to and 
distention of the inflamed part are diminished; and the vessels generally 
are placed in the condition for their natural offices of secretion, which 
their extreme tension had before interrupted. It is quite possible that 
this operation of antimony, and another more directly exercised on the 
inflamed vessels, maybe dependent on a chemical de-oxidating influence 
attaching to the protoxide of the metal as before hinted at(§ 494), and 
this notion would account for the greater tolerance of the medicine under 
inflammatory disease, which involves a process of hyperoxidation. These 
views are, how T ever, at present, no more than hypothetical, and might 
with advantage be tested by experiments on the lower animals. 

507. Another great remedy in inflammation is mercury, alone or com- 
bined with opium. The combination of calomel and opium was first 



262 



PROXIMATE ELEMENTS OF DISEASE. 



employed by Dr. Hamilton of Lynn Regis; and the rules which he pro- 
posed for its use have hardly been improved on. After a sufficient vene- 
section and a full purge, he gave from one to five grains of calomel with 
from one-fourth to one grain of opium every six, eight, or twelve hours. 
When much fever was present with dryness of skin, he added tartar 
emetic and camphor. If no relief ensued in twenty-four hours, vene- 
section was repeated. Most practitioners admit the power of this re- 
medy, although some ascribe its efficacy to the mercury, others to the 
opium ; and the proportions of each have been variously altered. The 
beneficial effects of this remedy generally, but not entirely, depend on 
the mercury affecting the system, as manifested in adults by the fetor of 
the breath, and the tenderness and swelling of the gums ; and in child- 
ren, by spinach-like evacuations from the bowels. Improvement is, 
however, often manifest before these results take place. In iritis, the 
influence of mercury is quite visible in removing effused lymph; and it 
thus obviously in some way promotes absorption, as well as prevents 
effusion. The same " sorbefacient" operatiou is seen in the effect of 
mercury in removing the callous margin of indolent syphilitic ulcers, and 
in promoting the spread of phagedenic ulcers. Dr. Farre thinks that 
mercury destroys the red particles of the blood, and causes in the sys- 
tem a disposition to erythematic inflammation, which is incompatible 
with phlegmonous or plastic; but this is opposed by the fact that lymph 
is thrown out and granulations form and healthy ulcers heal during mer- 
curial action. It will be useful to give briefly a view of the operation of 
mercury and opium ; for although we cannot be confident as to its entire 
accuracy, yet it is founded on what is best known of the effects of these 
medicines, and may therefore be a guide in their administration. 

The opium is useful in preventing the calomel from purging, and 
especially in subduing the nervous irritation attending inflammation, and 
which we have found to be one cause of that sympathetic excitement 
w T hich, when complete, constitutes fever (§ 440). This salutary effect of 
opium alone is sometimes seen when the vascular excitement has been 
subdued by a large blood-letting, and in cases in which nervous irritation 
forms a chief element of the disease: here a full dose of opium will 
subdue the remains of the inflammation better than any other antiphlo- 
gistic remedy; it seems to paralyze those sympathies which are concern- 
ed in' renewing or maintaining the excitement of inflammatory fever. So, 
too, in combination with mercury, the opium exercises this narcotic in- 
fluence; whilst the mercury prevents its astringent effect on the secreting 
organs (§§ 66, 173). The mercury acts further: it augments the biliary 
and intestinal secretions; sometimes inducing copious mucous and bilious 
evacuations; and from its effect in iritis, it maybe presumed to facilitate 
the solution and removal of effused lymph. How it has this effect is 
quite uncertain; probably it is by changing the condition of the blood, 
by a diminution of the fibrin and white corpuscles, the increase of which 
is much concerned in contributing to the changes of inflammation. So 
we find mercury chiefly useful where the blood is very much buffed, and 
there is tendency to copious fibrinous effusions, as in inflammations of 
serous membranes and croup. Calomel and opium have little influence 
over high inflammatory fever; and the system thus excited generally 



INFLAMMATION TREATMENT — COUNTER-IRRITANTS. 263 



resists the mercurial action. This remedy has no further sedative effects 
than those which proceed from its action on the intestinal canal; and 
unless to produce this action, it is not well adapted for the earliest stage 
and most active forms of inflammation. In these circumstances, blood- 
letting is more required with mercury than with antimony; and if fever 
returns during the action of mercury, blood-letting or active purging may 
be necessary to reduce it. In fact, the operation of calomel and opium 
is less antiphlogistic, and more alterative, than that of blood-letting or 
antimony: it is inferior to them in the power of reducing inflammatory 
fever and active inflammation; but it is superior to them in arresting and 
removing the more plastic products of inflammation. Besides this com- 
paratively slow influence produced by mercurial preparations generally, 
there are others more peculiar to calomel, which render it a most useful 
remedy even in active inflammations ; when given in large doses (from 
grs. v to 9j) it acts as a powerful cholagogue, and often causes the evacu- 
ation of dark green matter, which, according to the examination of Dr. 
G. Bird, resembles the coloring matter of the blood rather than bile, in 
composition. This operation of calomel does in truth resemble that of 
blood-letting, being more actively antiphlogistic than that of small doses. 
This mode of exhibition has been much used in India, and in this country 
has been employed with much success by Dr. Chambers. The chief 
evil attaching to it, is its tendency to induce inflammation of the large 
intestines and dysenteric straining; and for this reason it cannot be long 
persisted in. 

508. As considerable aids in the treatment of inflammatory fever, 
although quite inefficient alone, must be mentioned various saline medi- 
cines, such as nitrate of potass, and the alkalies combined with vegetable 
acids. Diluted solutions of these allay thirst, and seem to cool the fever; 
hence they have obtained the title of refrigerants. It is uncertain how 
far they may operate in diminishing the cohesion of the corpuscles and 
excess of fibrin in the blood (§ 438); but we can distinctly trace their 
good effect in augmenting the secretions, particularly that of the kidneys 
(§ 256). They are all more or less diuretic ; and most of them also 
supply an alkaline base, which, by uniting to the lithic and lactic acids 
formed in the blood, facilitate the separation of these matters by the 
kidneys. Colchicum and digitalis are sometimes reckoned among anti- 
phlogistic remedies; but in common inflammation, they are of very 
inferior power. In the absence of high fever, colchicum somewhat 
resembles mercury in its special action on the secretion of the liver, and 
it augments the elimination by the kidneys (§ 257); and digitalis acts 
as a diuretic, as well as a sedative on the irritability of the heart : but 
during severe inflammation, these effects are scarcely produced by doses 
which it would be prudent to administer. The same remark is applica- 
ble to hydrocyanic acid, and various preparations of aconite. There can 
be no question that both of these are capable of depressing the action of 
the heart, and thereby of reducing the force of the circulation; but in 
order to have such an effect during the excitement of active inflammation 
it would require large and dangerous doses. 

509. The utility of counter-irritants as a remedy for several elements 
of local inflammation has been already noticed (§§ 493, 496) ; but their 



264 



PROXIMATE ELEMENTS OF DISEASE. 



operation is positively injurious in sthenic inflammation during the preva- 
lence of fever. They then add to the excitement of the system ; and in 
proportion to the inflammation which they excite, they prove a new source 
of the inflammatory changes in the blood (§ 438). But after the fever 
has subsided under the influence of remedies, or is exhausted by time, 
the advantage of counter-irritants predominates. The seat of their 
application, too, ought to have regard to the excitability of the vascular 
system: where this is great, the counter-irritation should be more remote 
from the seat of inflammation ; where the excitability of the vessels is 
much reduced, blisters may be applied in close vicinity to the affected 
part. Blisters and suppurating counter-irritants, which cause copious 
discharge, are the most useful: tending to draw away the remains of 
inflammation, and to promote the removal of effused matters left by it. 
These become chief remedies as inflammation inclines to a chronic state, 
or w T here it has left such structural changes as cannot be speedily 
removed. 

510. The antiphlogistic regimen comprises the avoidance of all circum- 
stances and agencies capable of exciting or fatiguing the body or mind 
of the patient. Absolute rest in bed, in a very quiet, rather dark, yet 
cool and carefully ventilated apartment, is most favorable to the restora- 
tion of tranquillity to the circulation. The exclusion of noise, bustle, 
and other causes of excitement, and the careful removal of all irritating 
excrementitious matters must not be omitted. 

The antiphlogistic diet comprehends the same negation of all irritating, 
stimulating, and the more nourishing articles of food. The proteinaceous 
materials, meat, eggs, and in severe cases, even bread and milk are to 
be prohibited, as well as all oily nutriment, which tend to increase the 
heat of the body; amylaceous, gummy, and saccharine matters may be 
taken sparingly, and are best exhibited in thin fluids, such as barley- 
water, tea, weak gruel and arrow root, and the like. The thirst generally 
present suggests the need of diluents, which are further useful in cooling 
the body, and in promoting the action of diuretic, diaphoretic and other 
evacuant medicines ; but even these, if used to excess, tend to oppress 
the stomach and disturb the heart's action ; and in cases of inflammation 
of the lungs and of mucous membranes, may prove hurtful by augmenting 
the bulk of the circulating fluid. When fever is present, the total loss 
of appetite is a sufficient guide to the necessary abstinence from food, 
and the stomach often will not retain or digest any but the weakest 
nutriment ; but this is not the case in all cases of inflammation where 
the restraint may be equally called for. 

511. Exhaustion. Depression from poison. (See Table, 16 and 17.) 
The exhaustion ensuing after long-sustained excitement of inflammation 
and fever often renders stimulants and tonics, as w r ell as a generous diet, 
necessary in the after treatment; but the greatest circumspection is 
necessary to be sure that these measures shall be proportioned to the 
wants of the case, and not pushed so early or so far as to rekindle the 
inflammation afresh, or to produce other disorder in the weakened organ- 
ization. No diffusible stimulant is more generally or safely applicable 
at this juncture than preparations of ammonia, which are conveniently 



REMOVAL OF THE PRODUCTS OF INFLAMMATION. 



265 



exhibited by adding the carbonate of ammonia to the saline draught. 
It seems possible that its utility may partly depend on its supplying the 
azote necessary to convert amylaceous and saccharine nutriments into 
albuminous or gelatinous principles, according to a conjecture lately 
proposed by Dr. Alison. Alcohol and ether more obviously act by 
supplying a material for animal heat, which may also prevent the oxygen 
of the blood from preying too much on the materials of the textures. 
Similar aids are required, but are less successful in supporting the system 
against the pernicious influence of purulent or gangrenous matter result- 
ing from the inflammation. Even in cases of suppuration, the occurrence 
of the premonitory rigors, the diminished strength of pulse and heat of 
skin, point out the time for changing the reducing plan for one more 
supporting ; but the degree to which the change is made must depend 
on the symptoms, and on the efficiency with which nature is attempting 
the process of limiting the destroyed part. When suppuration has com- 
menced, there is no probability of its retrogression : and therefore the 
obvious indication is to promote its completion and to prevent its exten- 
sion and the diffusion of the pus through adjoining parts and through 
the system. This indication is best fulfilled by local stimulants, espe- 
cially heat combined with moisture. This promotes determination of 
blood to the part whereby the pus globules are fully developed and the 
compressed fibrin and tissue dissolved and absorbed (§ 461), whilst 
surrounding vessels, inflamed but less obstructed, are throwing out a 
barrier of lymph, retaining its vitality and resisting the action and pro- 
gress of the pus in all directions, except that in which the textures yield 
most, and through which it finds vent : this is promoted by various expe- 
dients described in surgical works. The local treatment of gangrene 
also requires more or less of the aid of stimulants to aid the process of 
separation or sloughing of the dead from the living parts. It is probable 
that in all cases, some purulent or some gangrenous matter finds its way 
into the circulation ; therefore, in addition to stimulants and tonics, anti- 
septics (such as chlorinated liquids, nitromuriatic acid, chlorate of potass 
and creosote,) are sometimes with advantage given internally to counter- 
act the septic influence; and above all, the secretions are to be kept 
free to promote the elimination of the morbid matter (§§ 260, 443), the 
foul nature of which is often evinced by the fetor and disordered appear- 
ance of the feces and urine. For a similar reason, foul suppurating, 
and gangrenous sores are dressed frequently, and their discharge cor- 
rected and promoted by antiseptic and alterative applications. 



18. The removal of the 'products of Inflammation. 

512. The serum, liquor sanguinis, and the healthier kind of fibrin 
and exudation corpuscles (§ 424), are removed by the natural process of 
absorption (solution by conversion into tritoxide of protein or other solu- 
ble products, and subsequent endosmosis into the adjoining vessels), 
aided by various remedies before mentioned, particularly blisters and 
other counter-irritants, mercury, iodine, iodide of potassium, colchicum 
and other diuretics. As a free circulation of blood probably promotes the 
removal of effused solids, partly by further oxygenating them, the idea 



266 PROXIMATE ELEMENTS OF DISEASE. 

is suggested, that we may aid this process by the internal exhibition of 
agents which contain a large proportion of oxygen in loose combination. 
Nitric acid answers to this description ; and whether this be one mode of 
its action or not, I can affirm, from much experience in its use, that it 
is the best medicine that I know for the state of convalescence from in- 
flammations. In doses of 20 to 30 minims, three or four times daily, 
in some aromatic or mild bitter vehicle, it often cleanses the tongue, and 
improves appetite, circulation and strength. Its utility is limited by its 
tendency to irritate the bowels, but this result is rare. Products of ex- 
ternal inflammation are sometimes more speedily dispersed under the 
influence of what are called discutients, which are generally slight sti- 
mulant applications, such as a warm spirit lotion, or solution of hydro- 
chlorate of ammonia, common salt, or iodide of potassium ; and, in more 
chronic cases, by friction with liniments containing mercury, iodine, 
ammonia and spirit. These operate in various ways already explained, 
by promoting a free current of blood through the part without distention, 
and thus facilitating absorption ; by diminishing the atonic congestion 
left by inflammation; by promoting secretion or exhalation; by pressure, 
&c. The restoration of a vigorous state of the circulation and excreting 
function, is often necessary for the removal of copious effusions and de- 
posits left by inflammations. Thus, I have noticed that pleuritic effu- 
sions frequently show no signs of dispersion until the strength of the 
body begins to return under a restorative mode of treatment. From the 
researches of Mr. Gulliver, and others, it appears, that the longer an 
inflammatory product remains without becoming organized, the more 
does it abound in particles or granules of a fatty character, consisting 
of margarin and olein. This change, which is like that of atheromatous 
matter in arteries, and aplastic tubercle, probably depends on a sponta- 
neous conversion like that which occurs in the formation of adipocire 
from fibrin kept moist, and secluded from the action of the air. To 
prevent such a result, and, perhaps, to disperse it where begun, we na- 
turally look to means which increase the free circulation of arterial 
blood in and around the part ; which, either by its oxygen or other sol- 
vent agents which it contains, may dissolve away the solid fats, and 
assist to disperse the solid deposits. This subject will be reviewed 
under the head of Degenerations and Morbid Deposits. 

TREATMENT OF VARIETIES OF INFLAMMATION. 

513. The sthenic (§ 477) form of inflammation requires the whole 
array of antiphlogistic remedies to be directed with energy against it. — 
The prevalence of determination of blood, active vascular excitement, 
and the over-fibrinous condition of the blood, demand the free use of 
blood-letting, calomel, purgatives and antimony, at the onset ; and the 
full operation of mercury if the disease continue. In asthenic inflamma- 
tion, on the other hand, blood-letting is ill borne, and often can only be 
practiced locally; and the chief treatment is with antimony or mercury, 
and blisters, which, in the absence of high fever, may be employed at a 
much earlier period than usual. The diet, although light, must not be 
too spare, and may include such light nutriment as animal broths, milk, 



INFLAMMATION TREATMENT OF VARIETIES. 



267 



and farinaceous food. Mild stimulants may sometimes be required, espe- 
cially ammonia, in order to enable the system to complete the processes 
of protection and elimination which are ever needed during inflammation 
(§§ 443, 4). 

514. Acute inflammation (§ 478) demands a very prompt use of the 
suitable antiphlogistic remedies ; but the choice made of thein, and the 
extent to which they are to be pushed, will depend on whether the in- 
flammation be sthenic or not. Subacute inflammation is generally of the 
asthenic form ; and being less severe, as well as slower, in its progress 
and effects, it does not require such active treatment. It must not, how- 
ever, be neglected ; for its obscurity sometimes renders it dangerous ; and 
in an insidious manner, it sometimes seriously injures function and 
structure. Its long continuance, or liability to recurrence, renders it 
necessary to continue a moderate antiphlogistic treatment for several 
weeks. When lasting so long, it tends to become more asthenic, and 
the more lowering antiphlogistic remedies are no longer serviceable; and 
sometimes it is proper even to call in the aid of tonics and improved 
diet, whilst the local inflammation is treated with counter-irritants. — 
Mercury, with opium, is generally one of the most useful remedies in 
subacute inflammation. 

515. Chronic inflammation recedes still further from the inflammatory 
type, and borders more on congestion or disease of nutrition. The ab- 
sence of fever generally supersedes the need of the stronger antiphlo- 
gistic remedies — those for local inflammation being sufficient ; general 
blood-letting is needful only when plethora also is present; and even 
local blood-letting should not be too freely employed ; for it weakens the 
system, w T hich is generally already too feeble in chronic inflammation. — 
Counter-irritants are more constantly useful ; and their application should 
be varied according to the seat and extent of the inflammation. In in- 
flammations of serous membranes, a succession of large blisters answers 
best. For chronic inflammations of parenchymatous organs, and ulcer- 
ations of mucous membranes, counter-irritants, which excite pustules, 
or setons, are of more avail. Mercury is often useful, and so are other 
alterative medicines, especially salines, and the iodide of potassium. — 
Mercury is more suitable to the more sthenic forms, attended w 7 ith effu- 
sion of lymph, leading to tuugh thickening and induration of textures. 
Iodide of potassium is better adapted for chronic inflammation of an 
asthenic character, with reduced blood and strength, with tendency to 
ulceration, suppuration, or aplastic deposits. It is often requisite to keep 
up the general strength by the mildest tonics, such as sarsaparilla and 
mild bitters, and to allow a nourishing, but not stimulating diet, adapted 
to the digestive powers of the patient. Careful attention to the state of 
the excretions is particularly necessary. Courses of mineral waters, and 
change of air by gentle traveling, are often serviceable in chronic in- 
flammations. 

516. In congestive inflammation (§ 480), the treatment for congestion 
should be combined with that of subacute inflammation. If the subject 
be plethoric, general blood-letting would be proper ; otherwise local 
bleeding and various derivants or revulsives, among which cupping and 
dry cupping, or hsemostatic ligatures (§§ 318, 503) are the most effectual* 



268 



PROXIMATE ELEMENTS OF DISEASE. 



Rubefacient applications to an extensive surface, as large mustard poul- 
tices, and strong ammoniacal or mineral acid liniments, are of consider- 
able efficacy ; and their use can be renewed and varied daily for a long 
time. Mercury and antimony are both highly useful in the more active 
stage of congestive inflammations : the former especially for inflamma- 
tions of the abdomen, the latter for those of the lungs. In the absence 
of much irritation, iodide of potassium, mineral acids, and even quinine, 
sometimes help to disperse the congestive part of inflammation. So, 
too, in secreting structures, as the liver, kidneys, and mucous membranes, 
various stimulants which excite the secretion of the part, act in a similar 
way. In congestive inflammation, as in long continued congestion, the 
blood suffers from long stagnation in the affected part, and being spoilt 
(§ 191) may prove a cause of contamination to the rest of the blood in 
the body. Hence the propriety of using the various depurative remedies 
which increase the excretions, &c, and of resorting to iron, quinine, 
and nourishing food during the convalescence. For further particulars, 
see the treatment of congestion (§ 313, et seq.). 

517. The treatment of phlegmonous inflammation* is generally that 
for the sthenic form. Erysipelatous inflammation being generally asthe- 
nic, is not benefited by active antiphlogistic measures; and in some 
cases it is necessary to adopt quite an opposite treatment, by ammonia, 
wine, bark, &c. : this is where the influence of the specific poison (§ 482} 
predominates. In other cases, the reaction against this influence is v£ry 
vigorous, and requires moderation. Generally warm fomentations to the 
affected parts, a saline, sometimes with small doses of tartar emetic, and 
keeping the secretions free, answer best at first, and are, in a few days, 
to be gradually replaced by ammonia or wine, and bark or quinine, with 
improving nourishment.! A more decided counter-agent against the 
poison (as against other animal poisons) is a desideratum ; but scrupu- 
lous cleanliness in all points, and careful regulation of temperature and 
ventilation, are the best preventatives in hospitals and sick rooms where 
the effluvia from sores or wounds is apt to engender the disease. Punc- 
tures and incisions, which relieve the inflamed part by the discharge of 
blood and serum, cauterization by nitrate of silver, which, by exciting a 
different inflammation, arrests the progress of erysipelas — and mercurial 
ointment, which is supposed to modify its character — are the chief kinds 
of local treatment that have been found useful. 

518. Pellicular or diphtheritic inflammation is usually of an asthenic 
character, little benefited by blood-letting, but chiefly to be counteracted 
by mercury, which is the suitable remedy for all inflammations effusing 
lymph; and by local astringents, or even caustics, which, by powerfully 

* This term is used here in the sense in which Cullen employed it, as opposed to erythe- 
matic or erysipelatous. I mention this, because boils or furuncular inflammations are some- 
times of an asthenic character ; and with them not unfrequently the constitution requires 
support. 

f Erysipelas of the head and scalp is that which falls commonly under the observation 
of the physician; and although often attended with formidable symptoms, I have very rarely 
known it prove fatal. All the cases (twenty in number) under my care at the hospital have 
recovered in a period varying from one to four week?, under the general treatment recom- 
mended above, without any other local treatment than fomentations, where the patient likes 
them, very rarely a leech or two to the temple, and poultices to any succeeding boils. 



INFLAMMATION — TREATMENT OF VARIETIES. 



269 



exciting the vessels, change their action. Thus nitrate of silver, in sub- 
stance and in solution, hydrochloric and diluted nitric acids (one part to 
three or four parts of honey applied with a brush), and finely powdered 
alum, have been used with advantage in diphtheritic sore throat. In the 
croupy inflammations of children, the most effectual remedies are calomel 
freely used, antimony, and certain expectorant or attenuant medicines, 
which promote the more liquid secretions of the inflamed membrane. 
The aphthous inflammation of children is readily subdued by a solution 
of borax, or a weak solution of sulphate of zinc, using, at the same time, 
magnesia and mild mercurial aperients to correct the secretions of the 
alimentary canal. 

519. Hemorrhagic inflammations (§ 484) are often of the congestive 
kind; and the hemorrhage arises from the excessive distention of vessels, 
as in the hsematemesis that sometimes precedes gastritis, the bloody dis- 
charges of dysentery, and the hematuria which occasionally ushers in 
inflammation of the pelvis and tubes of the kidney (pyelitis). The he- 
morrhagic tendency exhibited in purpura, and sometimes combined with 
inflammation in lichen lividus, and ecchymosed erysipelas, I have often 
found connected with congestion and torpid action of the liver (§ 171), 
and accordingly benefitted by mercurial and saline aperients, followed 
by nitric or nitromuriatic acid. 

520. Scrofulous inflammation (§ 485) being generally asthenic, is little 
benefitted by blood-letting or other active antiphlogistic measures. Its 
disposition to produce early cacoplastic and aplastic effusions makes it 
important that it should be subdued, if possible, at an early stage, in 
situations where the formation of curdy pus or tuberculous matter would 
be injurious. In scrofulous inflammation of the lymphatic glands, 
warmth and moisture and discutient applications, (solutions of muriate 
of ammonia, iodide of potassium, warm vinegar,) are often useful in dis- 
persing the swelling before, it comes to suppuration. In internal inflam- 
mations in scrofulous subjects, as of the lungs, glands, and joints, local 
depletion is generally advisable, followed by free counter-irritation, such 
especially as may cause an external discharge of pus. Dr. O'Beirne 
and others recommend a free mercurial course for scrofulous inflammation ; 
but this I consider admissible only in the earliest stage of the disease, 
and in its more active forms; for I have found (what I believe is the ex- 
perience of most practitioners) that mercurialization greatly injures the 
constitution of scrofulous subjects, degrades the products of inflamma- 
tion, and promotes softening and ulceration in textures where deposit has 
already taken place. It seems to me that it is rather asthenic or chro- 
nic inflammation (§ 479), in subjects that are not scrofulous, that is 
benefitted by mercury, and not that especially occurring in the scrofu- 
lous diathesis. Preparations of iodine, especially the iodide of potas- 
sium, do sometimes appear to countervail low scrofulous inflammation; 
and their commonly salutary operation on the constitution renders them 
eligible medicines in scrofulous subjects. 

But the source of the peculiarities of scrofulous inflammation, and 
therefore the chief object for peculiar treatment, is the scrofulous diathe- 
sis or constitution; and as this seems to consist in a degraded condition 
of the plasma, or nutritive material of the blood (§ 211), often connected 



270 



PROXIMATE ELEMENTS OF DISEASE. 



with a deficiency of red particles (§ 185), an invigorating and nourish- 
ing treatment and regimen are especially indicated (§§ 218, 219), and 
may sometimes be employed even when low inflammation is present; 
this being counteracted by counter-irritation or other local antiphlogistic 
measures. Hence the best remedies in scrofula are tonics, nourishing 
diet, and other means calculated to improve the nutritive function and 
general health. Even the medicine that has attained the highest repute 
in the treatment of scrofula, may be considered as belonging to the class 
of nutriments. I allude to the cod liver oil, which has long been em- 
ployed on the Continent, and in a few places in this country, and was 
highly recommended in a monograph published by Dr. Hughes Bennett, 
in 1841. Its general adoption has, however, chiefly depended on the 
ascertained fact that it is equally efficacious when purified by animal 
charcoal, which removes from it its offensive taste and smell, which are 
great impediments to its being borne by patients. Commencing with a 
dose of a teaspoonful thrice daily (two hours after each meal,) and gra- 
dually increased to a tablespoonful, this medicine has produced in many 
scrofulous patients such improvement as quite to astonish me. It seems 
to give a new impulse to nutrition, for an amendment in flesh, color, and 
strength soon attends its use ; commonly the pulse is moderated, and even 
the appetite augmented, whilst more or less amelioration is generally 
manifest in the local inflammation. Thus scrofulous swellings diminish 
and even disperse ; enlargements of joints are reduced ; ichorous sores 
secrete a more laudable pus; the profuse discharge from abscesses and 
vomicae is lessened; and consequently hectic fever, night sweats, &c, 
are checked. The chief impediment to its use is its disordering the 
stomach and liver: the latter I have sometimes found to be remarkably 
enlarged during its exhibition. The utility of cod liver oil in tubercu- 
lous disease and its mode of action will be considered under the head of 
cacoplastic and aplastic deposits. Of other medicinal agents, the iodides 
of potassium and iron, other preparations of iron, bitters with alkalies, 
bark, or quinine, and mineral acids, have been found the most service- 
able. Equally important in the treatment are pure and mild air, espe- 
cially near the sea or on mountains; warm clothing; regular exercise, 
friction and other means to promote the superficial circulation; warm 
sea-bathing, or cold when borne (§ 79), followed by friction; a good pro- 
portion of wholesome animal food, with due regard to the state of the 
excretions. These measures are of great efficacy in the scrofulous dia- 
thesis, and are often useful even after inflammation has produced dis- 
ease ; for they do much to prevent its increase, and assist nature in re- 
moving or rendering inert, the cacoplastic, or aplastic matter. 

521 . The peculiarity in the treatment of rheumatic and gouty inflam- 
mation consists chiefly in the use of means calculated to eliminate the 
morbid matter, which is its cause (§§ 251 — 254), from the system. The 
remedies which best promote this object have been already mentioned 
(§§ 252, 254). But it must be remembered, that the inflammation and 
fever excited may be so high and sthenic, as to require active antiphlo- 
gistic measures before colchicum or mercury can be made to act; and 
this is particularly the case in acute rheumatism, in which inflammation 
is excited in many parts at once; and probably as a consequence (§ 438), 



INFLAMMATION — TREATMENT OF VARIETIES. 



271 



the blood becomes surcharged with fibrin. Here general blood-letting is 
necessary, not to remove the cause of the inflammation, but the inflam- 
mation itself. If, after blood-letting, the rheumatic cause abound still in 
the blood, which is commonly the case, it is proper then to give colchi- 
cum with alkalies, or iodide of potassium, or nitre in large quantities 
much diluted, (Gendrin,) and to continue such remedy for some time, 
until the morbid matter shall have been sufficiently eliminated. In 
asthenic cases, the use of bark, quinine, or other tonics, may be serviceable 
in improving the tone of the vessels after the irritation and exhaustion 
which the disease and its treatment have produced (§ 174). 

The infectious character of gonorrhoea and syphilis proves the specific 
nature of their cause ; but it is only of the latter that we can speak of 
a specific remedy. How mercury cures syphilis is quite uncertain. It 
is not by any property directly destructive to the virus; for the disease 
cannot be prevented from appearing by mercurial action ; and when pre- 
sent, it is not always cured by it. It is more probable that mercury acts 
as an alterative, by removing the callous indurations of syphilitic sores 
and swellings, and by increasing the secretions, and thus gradually eli- 
minating the syphilitic virus from the system. It is now well known 
that other remedies, which promote absorption and secretion, also promote 
the cure of syphilis, especially the iodide of potassium. Gonorrheal in- 
flammation generally tends to a spontaneous cure in a few weeks' time ; 
but this may be accelerated by mild antiphlogistic and demulcent mea- 
sures at first, and astringent injections and terebinthinate remedies sub- 
sequently. 



272 



CHAPTER IV. 

STRUCTURAL DISEASES, OR DISEASES OF NUTRITION— ULTIMATE AND 
PROXIMATE ELEMENTS. 



SECTION I. 

NATURE AND CLASSIFICATION. 

522. Although we have had frequent occasion to advert to the changes 
in the process of textural nutrition effected by inflammation, congestion, 
&c, and although nutrition might be included under the head secretion 
(§ 178), a primary element, yet it has seemed better to defer the notice 
of diseases of nutrition until now; both because the previous considera- 
tion of disorders of the blood and its vessels, gives the best introduction 
to them, and because we cannot strictly distinguish structural disease 
into ultimate and proximate elements. By analogy, indeed, we might 
infer that ultimate structural disease is that which affects elementary 
structures singly, such as muscular fibre, nervous matter, cellular tex- 
ture, &c. ; but we find structural disease rarely to be thus confined to 
one anatomical element, but rather to affect structures as they exist com- 
bined in more or less complexity. 

It will not be consistent with the plan of this work to give full details 
of structural disease, which belong rather to the department of morbid 
anatomy. It will be sufficient for our purpose, to notice the chief forms 
of diseases of structure, by tracing them through the alterations in the 
function of nutrition which produce them. This method will enable us 
to class these diseases in an arrangement corresponding with that applied 
to the elements of functional disease (§ 104), and under each head to 
state briefly what is known with regard to their nature and origin, and 
the remedies which influence them. 

As in the case of functional diseases, so of structural lesions, which 
are modifications of the function of textural nutrition, they may be com- 
prehended under the three heads, increased, diminished, and perverted 
nutrition.* 

* Although considerable advances have been made in pathological anatomy, and several 
new works devoted to the subject have appeared since the publication of the first edition of 
this treatise in 1843, it is satisfactory to me to find that in no material points, has the advance 
of knowledge superseded the views there given of the elements of structural disease, but in 
many instances these views have been signally confirmed and extended. Under these cix- 



NUTRITION AND ITS VARIETIES. 



273 



ELEMENTS OF STRUCTURAL DISEASE. 



DISEASED 
NUTRITION 



Increased = hypertrophy. 
Diminished =3 atrophy. 

" Induration. 



ALTERED 
MECHANISM 



Perverted 



Contraction 

Dilatation 

Obstruction 

Compression 

Displacement 

Rupture, &c. 



Softening. 
Transformation and degeneration. 

Cicatrices. 



Deposits 



Growths 



Euplastic 

Cacoplastic 

Aplastic 

Non- 
malignant 

Malignant 



False membranes, 
f Cirrhosis. 
J Fibro-cartilage. 
j Gray tubercle. 
^ Atheroma, &c. 
$ Yellow tubercle. 
I Calcareous matter, &c. 

C Cysts. 

< Tumors. 

( Hydatids, &c. 
( Carcinoma. 

< Encephaloma. 
( Melanosis, &c. 



It must be remembered that the division here given, simple as it is, 
is too precise to be rigidly applicable to many cases. Lesions of nutri- 
tion often graduate into each other, and are very commonly combined: 
hypertrophy of some textures frequently co-existing with atrophy of 
others, perverted nutrition being often combined with excessive or de- 
fective, and several of these different changes often occurring in succes- 
sion in consequence of the operation of the same cause. We have 
already found this to be the case with the results of inflammation (§ 479) ; 
and inasmuch as that process exaggerates the changes of nutrition, it 
has furnished us with many examples of the production of structural 
lesions. What we now have to notice are those changes which take 
place independently of distinct inflammation, and which are mere modi- 
fications of the process of nutrition or reparation which is continually 
going on in the textures of the living body.* 

523. As in inflammation, so probably in the ordinary process of 
nutrition, the material of which most of the organized solids are formed 
is the fibrin of the blood. This, by the formation of nucleated cells or 
nuclei and fibres, constitutes the basis of textures, which are afterwards 
further modified by growth and multiplication, and by the deposition of 
homogeneous, or hyaline matter in their interstices. Some structures 
are chiefly formed of the nucleated cells pressed together and consoli- 
dated in rows and layers, as in the epidermis and the epithelium of 

cumstances,I have added to, rather than modified the text; and in preference to new classi- 
fications and uncouth nomenclature, which it has been attempted to introduce from various 
foreign writers, I have retained my former division of the elements of structural disease, 
designated by terms in common use among British pathologists. For further valuable infor- 
mation on details of morbid anatomy. I would refer to the works of Rokitansky, Vogel, and 
Lebert, especially that of Vogel, which Dr. Day has very ably edited for English readers. 
[Phil., reprinted, 1847.] It is much to be regretted that Rokitansky's work has not been 
rendered likewise accessible; for he seems to me to be the most accurate and experienced 
of all continental morbid anatomists. 

* For an able summary of our present knowledge on the subject of nutrition, see Dr. 
Carpenter's " Human Physiology. 55 3d ed. [Chap. XIV., p. 593.] 

18 



274 



STRUCTURAL DISEASES. 



mucous membranes. In other textures, either cells are elongated into 
fibres, or primary fibres are developed in the blastema, as in fibrin; 
this seems to be the mode of development of filamentous, areolar, or cel- 
lular texture and its modifications, serous and basement membranes, 
fibrous and tendinous structures. In cartilage, the chief materials are 
peculiar cells contained in an amorphous solid, or an organized fibrous 
substance ; in bone, radiated earthy particles occur in the place of cells. 
In the first formation and growth of textures, the production and multi- 
plication of cells or nuclei from the plasma of the blood is necessary; 
and it is interesting to observe that in young animals, in pregnant females, 
and in the subjects of inflammation, the colorless corpuscles in the blood 
(§ 212), which probably are cell-germs, are much more numerous than 
usual (§ 418). But in the ordinary textural nutrition of adult animals, 
there is less need of the formation of new cells or germs; those already 
existing in the texture maintain the process by drawing nourishment 
from the blood-liquor, which furnishes the materials of all the solid tex- 
tures ; the formation of new cell-germs thus normally diminishes as age 
advances, and when then increased, it is usually the result of disease. 
Nutrition in all its stages is probably more or less a vital process: for 
although the chemical and physical formation of nuclei or cell-germs 
admits of imitation by the operation of minute granules of fat on an albu- 
minous fluid undergoing oxydation (§ 211), yet their progressive develop- 
ment, their growth into cells, their power of separation or secretion of 
certain matters from the blood-liquor, their power of self-preservation 
and reproduction, all are properties peculiar to living matter, and as such 
are to be regarded as ultimate facts or elements in physiology. When 
their laws shall have been more fully studied, we may hope to trace to 
these elements, varied in proportion and kind, corresponding elements 
in pathology, which will explain much that is at present obscure in the 
origin and nature of structural diseases. And we can already perceive 
in a defect of these attributes of life, an element of mal-nutrition, in which 
the vital process of development fails in one or more of its stages, and 
renders the material unfit to form part of a living texture. 

524. As nutrition depends on the blood for its material, and on the 
supply of arterial blood for the activity of the process, so it may be anti- 
cipated that changes of nutrition commonly arise from differences in the 
quantity and quality of the blood, and from variations in its arterial cha- 
racter. Hence diseases of nutrition are usually connected with diseases 
of the circulation and of the blood (§ 279), a moderately active circula- 
tion and a rich blood favoring nutrition; a poor blood (§ 260), and either 
too active or too feeble a circulation, impeding it; and a diseased quality 
or proportion in the elements of the blood (§§ 186, 211), rendering it 
depraved. These causes operate on the whole frame ; but they commonly 
affect some textures more readily than others, because the process of 
nutrition is naturally more active, and therefore is more speedily influenced, 
in some than in others. Thus fat and cellular texture are increased or 
diminished sooner than muscle, muscle sooner than tendon or bone, &c. ; 
and for similar reasons, degenerations and other changes of structure 
affect some parts more than others (§ 311). But structural diseases are 
more commonly partial from causes existing in the part ; and no causes 
are more common than those which affect the circulation of the part, so 



INCREASED NUTRITION — HYPERTROPHY. 



275 



that partial anaemia, congestion, determination of blood, and inflamma- 
tion, are the most frequent causes of partial structural disease. We have 
made a similar remark of diseased secretion (§ 159) and other elements 
of disease. If the nervous influence affects nutrition, it is probably 
through its operation on the circulation of the part. Thus a paralyzed 
limb wastes because, not being exercised, it is not so freely supplied 
with blood. The muscles of the limb of a frog, the nerves of which are 
divided, lose their irritability and waste also ; but Dr. John Reid has 
shown that by exercising these muscles by electricity, which promotes 
the circulation, both their irritability and nutrition are maintained. 



SECTION II. 

INCREASED ' NUTRITION HYPERTROPHY . 

525. Hypertrophy, as a disease, is always partial; for, although the 
whole body in cases of obesity acquires an enormous bulk, this is from 
the extraordinary growth of the adipose tissue, a part only of the frame. 
When the nutrition of textures generally has reached the acme of full 
health, there is no more increase, and the superfluous nutriment accu- 
mulates in the blood-vessels, causing plethora (§ 276).* Hypertrophy 

* [Although the development and growth of the body cease, as a general rule, at or 
about a determinate period — when the natural structures and full stature are attained — still 
some parts grow to the latest periods of life, unless interfered with by disease. This is 
especially true of the heart and arteries. Dr. Clendinning and M. Bizot have shown, not 
only that the heart enlarges with advancing years — though with a decreasing ratio of in- 
crease — but that its weight augments, and the thickness of its walls increases, and it thus 
acquires power in the same proportion as it acquires bulk. Every part, too, throughout life, 
has the ability to grow, according to its needs — in proportion as its function is discharged. 
So long as the ordinary conditions obtain, after the attainment of the average size, each part 
merely assimilates ; but when the conditions alter, and a part is necessarily more than usually 
exerted, it then manifests the ability of accelerating its growth — a reserve power of growth 
and development, put forward in moments of emergency. 

The term hypertrophy is now used to designate excessive natural growth, unattended 
with the formation of any unusual product. Still a distinction is to be observed between 
the increase of an organ by the uniform growth, or enlargement of all of its tissues, and the 
increase by excessive development of some one. We have an example of the former in the 
thickening of the epidermis under the influence of pressure, friction, and other external 
forces. For though its rate of waste is augmented, it does not grow thin, but thicker, until 
it is completely adapted to protect the cutis, from the greater sources of injury to which it 
may be exposed under new circumstances. It puts forth its reserve-power, which is suf- 
ficient not only to repair all amount of waste, but also to increase the quantity of the tissue 
to the amount required for the discharge of its increased functions. We see the same thing 
in the other tissues, particularly the muscles; as in a heart, for example, in which, from ob- 
structed valves, the blood is held back in the organ; and the heart or one of its cavities 
necessarily acts with additional force. But, although the waste of an organ is commensurate 
to its exercise, there is no diminution of size, but, on the contrary, increase, or hypertrophy. 
But a part may do more than grow ; it may develop itself, or acquire new structures for 
new functions it may be called on to perform. Examples of this are seen in the pregnant 
uterus, or when it is the seat of fibrous tumors; in the gall bladder; or an obstructed ureter. 

According to Mr. Paget, the conditions which give rise to hypertrophy, are three, namely— 
1. The increased exercise of a part in its healthy functions. 2. An increased afflux of 
healthy blood. 3. An increased accumulation in the blood of the particular materials which 
any part appropriates in its nutrition, or in secretion. Examples of the first kind are fur- 
nished by the muscular system, particularly those of organic life — as the enormous thick- 
ening of the muscular fibres of the urinary bladder in cases of strictured urethra. 

The increased afflux of blood to a part may be the cause, as well as the consequence of 



276 



STRUCTURAL DISEASES. 



may affect individual textures, or whole organs composed of many tex- 
tures: in the former case, it may be called simple hypertrophy (an ulti- 
mate element of structural disease) ; and in the latter, complex hypertrophy 
(a proximate element). Let us mention a few examples of each. 

526. Muscles become enlarged by full exercise alternated with suffi- 
cient repose, and a healthy and well-nourished condition of the blood. 
This increased development in the voluntary muscles cannot be called 
disease ; but I have seen it occur in the sterno-cleido-mastoid muscle, 
long the seat of convulsive motion, and by giving too great power to the 
muscle, it seemed to perpetuate the distortion. The best cure for this 
would have been DiefFenbach's operation of dividing the muscle, as in 
the case of squinting, in which certain muscles gain too much power 
and probably bulk. But muscular hypertrophy is chiefly morbid when 
it effects involuntary muscles. Thus, in the heart, it results from con- 
tinued excitement in sthenic subjects; and from the violence with which 
the enlarged heart moves and propels the blood, it produces various bad 
consequences. The muscular fibres of the bladder become hypertrophied 
in case of enlarged prostate, or other cause of difficult micturition : 
those of the stomach are so from stricture of the pylorus ; those of the 
bronchi become so in spasmodic asthma, and dyspnoea is the result. In 
these examples, (as in all others of true hypertrophy,) there is an in- 
crease of the amount of the proper tissue, that is, muscular fibres: in 
what mode these are produced, whether by new formation of cell-germs 
and subsequent elongation into fibres, or by splitting and growth of the 
original fibres, has not been ascertained. 

527. Hypertrophy of the interstitial filamentous textures of the lungs, 
liver, &c, occurs after long-continued congestion from disease of the 
heart, &c. (§ 311). In the cellular texture of the lower extremities, it 
appears to be a chief constituent of elephantiasis. Hypertrophy of the 
epidermis occurs in callosities of the skin, and corns, from continued 
irritation or pressure, which causes determination of blood to the part. 
Another form of hypertrophy of the cuticle is that arising from chronic 
inflammation in psoriasis, chronic eczema, and impetigo. The cuticle 
is here retained, and from its stiffness, it often cracks into chaps or rha- 
gades. In the more temporary or more superficial cutaneous flushes, 
congestions or inflammations of erythema, scarlatina, lepra, and pityria- 
sis, the superfluous epidermis is thrown off in a peeling of the skin, or 
in detached scales. But ichthyosis presents the most extraordinary in- 
stance of hypertrophy of the epidermis, its scales accumulating in a 
solid state, so as to form scales, or coarse bristle-like projections. These 
affections of the epidermis have their parallels in diseases of mucous 
membranes; but the secretions of these membranes being fluid, the 

hypertrophy. The transplantation of the spur of a cock to the highly vascular comb, is fol- 
lowed by the very rapid growth of that organ. The increased determination of blood to a 
bone, in consequence of partial necrosis, may give rise to hypertrophy of the entire bone. 

The third cause is illustrated by the rapid increase in size of the kidney, when its fellow 
is incapacitated from performing its function. 

For much valuable information on this subject, the reader is referred to the lectures of 
Prof. Paget, (a) which we have followed in the preceding remarks. — C] 



(a) Lectures on Nutrition, Hypertrophy, and Atrophy. — Lond. Med. Gaz., 1847. 



INCREASED NUTRITION — HYPERTROPHY, 



277 



nucleated cells, which on the skin would form solid scales, here are 
thrown off in the mucus, which presents an increased number of epithe- 
lium scales, as well as the mucous cells and a viscid amorphous fluid 
(§ 455). Such disordered secretion of the mucous membranes not un- 
frequently co-exists with cutaneous diseases; thus, bronchial congestion 
w T ith viscid secretion occurs in persons affected with psoriasis and lepra. 

528. Complex or hypertrophy of organs of a healthy kind may result 
from a more copious flow of blood to them, contingent on their increased 
use. Thus, the uterus becomes hypertrophied in pregnancy; the breasts 
during lactation; one kidney becomes enlarged when its fellow is inca- 
pacitated by disease. The brain is more developed in proportion to the 
active exercise of the mind ; and when this is carried too far, if inflam- 
mation, congestion, or some other vascular disorder, do not occur, the 
brain may become hypertrophied, and by its bulk being too great for its 
bony case, it compresses the vessels, becomes indurated, and, as an 
obvious consequence, its functions are more and more impaired. Thus, 
in young subjects who have been remarkable for precocity and activity 
of intellect, the brain has been over-nourished, and fatuity and coma 
have been the result. Mucous and cutaneous follicles sometimes acquire 
an extraordinary development after continued excitement, or without 
any such obvious cause. Bursse become enlarged in situations exposed 
to much pressure or friction, as on the shoulders of porters, the knees of 
housemaids, the elbows of miners, and the ankles of tailors. 

The hypertrophy of the liver and spleen in protracted ague, may per- 
haps be referred to the frequent repetition and long continuance of the 
enormous congestions which this disease induces in these organs (§ 310). 
I have known a similar enlargement ensue after prolonged exposure to 
cold and wet. But in some cases, no such external cause can be traced ; 
but the hypertrophy must be referred to a peculiar condition of the circu- 
lation of the affected organs, or to an unusual activity in their nutrient 
molecules. To this obscure category may be appended the case of en- 
largement of the thyroid gland in bronchocele. 

The fatty enlargement or hypertrophy of the liver, and of adipose 
texture, may in many cases be referred to the reception of a large quantity 
of fat through the food, or a defective performance of those functions by 
which fat is eliminated from the system (§ 224); and in all respects the 
increase of fat may be viewed as less indicative of vital activity of nutri- 
tion, than of a predominance of its chemical material in the blood. 

529. The treatment of hypertrophy must depend on the pathological 
cause which induces it. In most cases, this cause is some variety of 
hyperemia, and the treatment suitable for the variety is to be employed ; 
(see Congestion, Determination of blood, and Inflammation.) But some 
remedies seem especially calculated to counteract the hypertrophy which 
these elements induce; such are iodine and its preparations, mercury, 
alkalies, and, in the more sthenic cases, sedatives and evacuants, together 
with low diet. The same remedies are occasionally useful also in hyper- 
trophy less distinctly connected with hyperemia, as bronchocele. In all 
cases, it is proper to attempt, as much as possible, to remove or counteract 
the exciting causes of hypertrophy, as by tranquilizing the circulation 
in hypertrophy of the heart; by soothing irritations of the stomach, blad- 



278 



STRUCTURAL DISEASES. 



der, &c, in obstructive diseases of these viscera; removal from malarious 
districts in case of visceral enlargements, &c. 



SECTION III. 

DIMINISHED NUTRITION ATROPHY. 

530. Atrophy, unlike hypertrophy (§ 525), may be a general disease; 
that is, all parts of the body may waste so much as to impair their func- 
tions. General atrophy, marasmus, or emaciation, consists in a removal 
of a considerable amount of the textures by decay and absorption, with- 
out a sufficient reparation by nutrition (§ 523). The organic materials 
of the body are not persistent, but are more or less prone to decay, 
becoming effete or worn out in a limited period of time : or as Dr. Alison 
expresses the same fact, the vital affinities which hold them together, 
cease, and they become obedient to common chemical affinities which 
tend to their dissolution ; the oxygen conveyed into the blood in respira- 
tion being a chief instrument in their decomposition. But in the healthy 
body there is a reparatory process continually countervailing this decay, 
by the deposition of new materials whose vital affinities are energetic, 
and able to maintain the integrity of the textures (§ 523). Hence the 
causes of atrophy may be divided into the circumstances which promote 
decay, and those which impair or prevent reparatory nutrition. Among 
the former, may be counted various influences which greatly reduce the 
vital powers, such as excessive and prolonged exertion, or excitement, 
want of sleep, extreme anxiety of mind, or continued suffering; under 
any of these, a person is familiarly said to be "worn to a shadow," with- 
out any more distinct disease taking place. But on examining the urine 
in such cases, it will often be found to contain an excess of urea, result- 
ing from the decay of textures. This secretion is also sometimes alka- 
line, and unusually prone to decomposition; and the intestinal and cuta- 
neous excretions sometimes exhibit an uncommon fetor, arising from the 
same tendency to putrescence. A fever of a low or hectic kind may be 
excited as a secondary result of these changes, and this fever is mistaken 
for the cause of the wasting. In cases of marasmus from excessive 
secretions or drains from the body, there is often also proof of accelerated 
decay ; thus, diabetes mellitus reduces the body, not only by perverting 
and draining off its nourishment (§ 255), but also by promoting the decay 
of textures which is manifest in the increased amount of urea excreted. 
Fevers and various acute diseases attended with much excitement, in 
like manner exhaust the vitality of the textures, and promote their decay, 
which takes effect especially as the disease declines, when the emaciation 
becomes most obvious. 

The circumstances which impair or prevent reparatory nutrition are 
several, and may occur in any or all the steps of the nutritive process, 
from the reception of food into the system, to its appropriation and assi- 
milation to the living textures. As examples in this series, may be men- 
tioned — 1. Defective quantity or innutritious quality of food (§ 58, et 



DIMINISHED NUTRITION — ATROPHY. 



279 



seq.); 2. Disorder of some part or parts of the digestive apparatus, such 
as extreme dyspepsia, diarrhoea, &c, which prevent the formation of 
chyle ; 3. Diseased mesenteric glands or tumors obstructing the thoracic 
duct, intercepting the supply of chyle to the blood ; 4. Perversion of the 
assimilating process by which chyle is converted into blood (§ 253). as 
in diabetes mellitus and chylosus ; 5. Defect in the formation of fibrin 
(§ 196) and albumen (§ 221) of the blood, the materials of nutrition, so 
that, instead of becoming the plastic material for repairing the texture, 
they have a tendency either to pass into decomposition, as in malignant 
fevers* (§ 257), or to concrete in a cacoplastic or aplastic form, as in 

* My friend, Dr. Hodgkin, considers a suspension of textural nutrition to be a chief cause 
of the phenomena of fever, and has very ingeniously applied this notion to explain many 
of the symptoms. — Lectures on Morbid Anatomy of Serous and Mucous Membranes, vol. ii. 
p. 490. Rokitansky, and other German pathologists, consider that typhoid fevers depend on 
the production, in the body, of an organic matter having some resemblance to malignant 
formations. To this, they apply the term typhus-material, and indicate the follicles of the 
intestines, and the parenchyma of the lungs, as the chief places of its deposition. Under 
the microscope, however, this matter exhibits nothing to distinguish it from bad fibrin or 
cacoplastic lymph; and in accordance with the view in the text, I consider it to be such, and 
tending to involve in a process of sloughing the excretory follicles of the intestines by which 
it is attempted to be thrown off, or inducing a deposit in the lung, which has various perni- 
cious tendencies (§ 474). 

[Rokitansky, Vogel, Engel, and most of the German pathologists, describe the " typhus- 
material," and believe it to be an important pathological element in most cases of typhus. It 
occurs, according to them, as a more or less firm lardaceous mass of a yellowish or whitish 
color, deposited, most frequently, in the intestinal canal, between the mucous and muscular 
coats, in Peyer's glands, and in the mesenteric glands ; less frequently in the spleen and lungs, 
and in- and under the mucous membrane of the trachea, and in the bronchial glands. Dr. 
H. Bennett, in an interesting paper on the morbid appearances of typhus as it occurred in 
Edinburgh in 1846 and 1847, published in the Edinburgh Monthly Journal for 1847, found 
the typhous deposit in the lungs, spleen and intestinal canal ; and confirms the views of the 
German pathologists. 

It may be either in a fluid or solid form. Engel says the " fluid matter is a viscid opaque, 
greenish-brown material, which, when allowed to remain at rest for some time, deposits an 
abundant sediment of epithelial cells, crystals of ammonia-phosphate of magnesia, and brown- 
ish flocculent coagula, whilst the fluid itself remains of a brownish or reddish color, and con- 
tains a considerable quantity of albumen ; it undergoes no other change than that of decom- 
position. The solid portion of the typhous product appears in the solitary and Peyerian glands 
of the small intestines, in the follicles of the large intestines, and in the mesenteric glands; 
it assumes the forms of these various parts in which it occurs, has a soft, pulpy consistence, 
a grayish-red color, and appears, shortly after its deposition, as a finely granular substance, 
mixed with blood corpuscles, and seems to be chiefly composed of albumen (a). Examined 
beneath the microscope, Vogel found this substance appearing il as an amorphous, slightly 
granular mass, of a brownish- white color, within which a large quantity of small-sized cells 
were deposited. These cells had an irregular roundish form; the majority were below 
1 -300th of a line in diameter; a few measuring from 1-1 50th to l-200th of a line; some 
were distinctly nucleated. By treatment with acetic acid, the amorphous substance became 
transparent, and gradually disappeared, upon which, very small cells (cell-nuclei 1) with 
sharp outlines came distinctly into view, being unaffected by the acid. Both cells and blas- 
tema were dissolved by ammonia, and by caustic potash. The glands of the colon contained 
a substance exactly similar to that found in the mesenteric glands, and in those of the small 
intestines." (b) 

Dr. Bennett says — " The minute structure of the typhous deposit varies in different situa- 
tions. In the lungs, spleen and intestinal canal, it contains, at an early stage, a number of 
roundish or irregularly shaped corpuscles. They are about the 100th of a millimetre in dia- 
meter, contain several granules, with a nucleus about the 500th of a millimetre in diameter. 
Acetic acid renders them more transparent. They are conjoined with numerous granules 
and molecules, which become more abundant as the process of softening advances. In the 



(a) Schmidt's Jahrbiicher, No. 7, 1845. Lond. Med. Gaz., vol. xxxvi., p. 1216. 

(b) Clymer on Fevers, p. 237. Phil., 1846. 



280 



STRUCTURAL DISEASES. 



tuberculous diseases ; 6. Excessive discharges of various animal fluids, 
of blood, pus, serum, milk, semen, mucus, &c. ; or morbid growths, 
which monopolize the nourishment of the body, such as tumors of va- 
rious kinds, particularly cancer; 7. Parasitical creatures, such as hyda- 
tids, worms, &c. 

531. A consideration of the above list of causes of emaciation, will 
show how uncertain it is as a symptom if it be taken alone ; but when 
traced to its cause, it is a very important index of the amount to w T hich 
that cause operates on the living body. Emaciation will rarely continue 
or advance to an extreme degree, without structural changes which ren- 
der the cause permanent; hence, extreme marasmus is generally con- 
nected with tuberculous disease, carcinoma, (especially of the stomach,) 
or some serious organic disease. The chief exception to this is diabetes, 
the intractable persistence of which is involved in much obscurity. 

532. Partial atrophy, the reverse of partial hypertrophy (§ 528), com- 
monly arises from defective supply of blood to the part. Sometimes, the 
defective supply is from the disuse of the part; thus the eye wastes in 
confirmed blindness; muscles and w T hole limbs become atrophied from 
disuse in paralysis and anchylosis; the testicle and the mamma waste 
with age, &c. Frequently, partial atrophy in an organ succeeds the 
changes induced by inflammation or other structural disease; the matter 
effused swells some parts, compresses others of the texture, and, by pre- 
venting a due supply of blood, causes a subsequent atrophy. This is 
especially the case when the products of inflammation or congestion are 
cacoplastic, as in cirrhosis of the liver, and granular disease of the kid- 
ney, in the consolidation of the lung caused by pleuro-pneumonia, &c. ; 
the deposits here produced, tend to contract and compress the vascular 
structure, and thus deprive the organ of its nourishment ; it accordingly 
shrinks in size, or, in the case of the lungs, the texture may become thin 
and emphysematous. In chronic pneumonia and phthisis, also, many 
blood-vessels in the lung become obliterated, and the texture may either 
waste or further degenerate, according to its condition. Atrophy of the 
heart and brain have sometimes been found connected with ossification 
and partial obstruction of the arteries supplying them. The dwindling 
of limbs in children, and the lameness in old persons from shrinking of 
the neck of the thigh bone, appear to depend on similar impediments in 
the vessels supplying the parts. 

533. The treatment of general atrophy (§ 530) must be directed to 
remove or obviate the cause, where that is practicable, to supply proper 
and adequate nourishment, and to promote the healthy action of the 
digestive, assimilatory, and circulatory functions. The means of fulfill- 
ing these indications, where attainable, would require too lengthened a 
detail to be introduced here : it must suffice to mention the chief reme- 
dies and measures to be opposed to the several pathological causes of 
atrophy. 

mesenteric glands, a higher degree of cell formation takes place. Cells are formed about 
the 50th of a millimetre in diameter, containing from two to six, and sometimes even more 
nuclei, which become very distinct, with thick edges, on the addition of acetic acid, whilst 
the cell wall is partially dissolved. The same cells may occasionally be seen in the ele- 
vated typhous deposits of the intestinal glands. Sometimes, the only appearance observa- 
ble in the deposit, is that of numerous molecules and granules mixed with blood corpus- 
cles."— C] 



ATROPHY TREATMENT OF. 



281 



Atrophy, from excessive or prolonged exertion, is to be treated by a 
sufficient amount of rest and nourishment, with wine or other stimulants 
also, if exhaustion still prevails (§ 84) ; that from anxiety of mind, suffer- 
ing, or sleeplessness, by various medicinal narcotics and change of air 
and scene, as well as by measures calculated to soothe under the particu- 
lar circumstances. The effect which opiates and other narcotics some- 
times have in diminishing the urea excreted in such cases, points out 
that these remedies tend to control decay, and they may in some cases 
be aided by mineral acids and various tonics. The same remedies are 
useful in diabetes mellitus, the marasmus of which is, however, to be 
still further checked by withdrawing all articles of food that can be 
converted into sugar — that is, all farinaceous, amylaceous, saccharine, 
and gelatinous matters (§ 256). I have generally found the excessive 
discharge and the emaciation of diabetes to be effectually controlled by 
the full application of this rule, but never by its partial observance, as 
recommended by Dr. Prout. 

The counteraction of the circumstances which impair or prevent repa- 
ratory nutrition (§ 530), comprises the treatment of the several diseases 
and causes of disease before enumerated under the seven heads, which it 
is not necessary to recapitulate. In most of these, the use of food as 
nourishing as the stomach can digest, and of tonics, medicinal and 
hygienic, as bracing as the body can bear, with due attention to the 
regularity of the excretions, affords the best chance of resisting or 
retarding the emaciation; and their utility will^nuch depend on the 
judgment with which they are applied. The utility of fat in the process 
of nutrition has been several times pointed out (§§ 66, 211, 224), and in 
addition to a fair allowance of milk, butter, and fat in food, or instead of 
them where they disagree, the cod-liver oil is a valuable remedy in 
atrophy. It is most suited to scrofulous cases, but I have experienced 
its utility in convalescence from fevers, and from prolonged and wasting 
attacks of rheumatism. 

534. As partial atrophy often arises from defective circulation in a 
part, it may sometimes be counteracted by measures calculated to pro- 
mote the passage of blood through that part. Thus, muscles wasted by 
disuse are sometimes increased and strengthened by blisters, stimulant 
frictions, electricity, and exercise. Atrophy following inflammation or 
congestion may sometimes be advantageously opposed by the remedies 
for the results of these conditions, especially iodine in combination with 
tonics, as iodide of potassium and sarza, iodide of iron, &c. In this and 
most other cases of structural disease, although treatment can do little to 
remove partial atrophy already induced, yet it may sometimes retard its 
increase by restoring a more healthy circulation throughout the body. 

[It has been ascertained by the experiments of Dr. John Reid,* that 
the atrophy of paralyzed muscles is due to their disuse, and that their 
nutrition is sustained when they are artificially stimulated to action. 
Mr. Paget, in the excellent lectures before quoted, observes that, when 
a person has had hemiplegia, the paralyzed limbs remain incapable of 
action long after the brain has, to all appearances, recovered its power, 

* Edinburgh Monthly Journal of Medical Science, May, 1841. 



282 



STRUCTURAL DISEASES. 



This abiding paralysis is not the consequence of any continuing disease 
of the brain, but should be ascribed to the imperfect condition of the 
muscles through inaction. So long as the state of the brain makes volun- 
tary action impossible, the muscles are suffering atrophy ; then, when 
the brain recovers, they are not in a state to obey its impulse, they are 
degenerate; and their inaction continuing, they degenerate more and 
more, and finally never recover their function. We ought, when muscles 
are paralyzed through disease of the nervous centres, to give them arti- 
ficial exercise: as exciting the reflex movements — by electricity and other 
means, which will ensure their nutrition, and when the nervous system 
recovers, they may be in a condition to act under its impulse. It has 
been suggested,* that, in cases of hysterical paralysis, in which the condi- 
tion of the nervous system suspends, for a time, its functional influence 
over the muscular parts, and in which there is every reason to hope that 
this influence will, in some way or other, be restored, this treatment may 
prove especially applicable. — C] 

PERVERTED NUTRITION. 

535. Under this head are comprehended all those changes of textural 
nutrition that go beyond mere degrees of plus and minus in the natural 
molecules of the textures; they either alter the quality of the texture, or 
form new textures, growths, or deposits, in connection with the normal 
texture. These changes often comprise partial hypertrophy and atrophy 
as well; and in so far as they do so, the observations already made with 
regard to those elementary changes may be extended to these, but with 
new additions. 



SECTION IV. 

INDURATION AND SOFTENING. 

536. We have mentioned both induration and softening to occur as 
the results of inflammation; softening being commonly connected with 
the increased secretion and absorption occurring in acute inflammation 
(§ 427); or during the dissolving process of suppuration (§ 461) ; and 
induration being rather a sequel of the more chronic kind, which causes 
a continued overflow of the solid nutritive matter (§ 479). Both these 
changes sometimes take place independently of complete inflammation; 
but they probably, in most cases, depend on some of its elements. 

537. Induration is constituted by an increased deposit of solid matter 
in a structure, or by compression of that structure, or by both. In some 
cases of insanity, the inner table of the skull acquires the hardness of 
ivory. In newly-born children, the skin acquires an unusual hardness 
and rigidity, rendering them " skin-bound." Glands and other soft 
compound structures sometimes become hard without inflammation. Pro- 

* British and Foreign Medico-Chirurgical Review, vol. i. p. 423. 



PERVERTED NUTRITION — INDURATION AND SOFTENING. 283 



bably, in all these cases, there is prolonged determination of blood to the 
parts, which causes an exaggeration of the nutritive function ; but the 
matter exuded is more hyaline (§ 523), or simply granular (§§ 452, 3), 
than consisting of highly organized cell-germs or fibres; hence the result 
is not simple hypertrophy or increased growth, but a more condensed and 
more uniform texture. A somewhat similar change is produced in the 
lung by compression by liquid effusion or a solid tumor, especially when 
the lung itself is also inflamed, as in pleuro-pneumonia, in which the 
pressure restrains the full development of the exudation corpuscles. The 
induration of cartilage, &c, by osseous deposit is more properly trans- 
formation than simple induration. So induration of the liver, kidneys, 
and other organs, generally comprises intestinal deposits, and other changes 
of structure. 

538. Softening arises from different causes in different textures. In 
some instances, the cause, being peculiar to the structure, may be called 
specific. Thus in the bones it proceeds from defective deposition of 
phosphate of lime, the earthy matter which gives solidity to these struc- 
tures.* The softening of the stomach found after death is caused by the 
solvent action of the gastric juice. The softening of various textures, 
especially muscles, in fevers and other cachectic states, is connected with 
a defect of fibrin in the blood (§ 196): the same cause which removes 
this fibrin, and prevents its formation (§ 216), apparently dissolving or 
loosening the fibrinous parts of solid textures. In several cases of ca- 
chectic diseases in intemperate persons, commonly with degeneration of 
the liver and kidneys, I have found after death a general softening of the 
textures, which, under the microscope, exhibited an unusual predominance 
of oil globules (§ 258). In other instances, softening is a variety of 
atrophy, arising from a defective supply of blood ; so that the texture of 
a part decays, and is absorbed away faster than it is repaired. Thus 
softening of the brain and heart is sometimes found connected with ossi- 
fication and partial obstruction of the arteries supplying these parts. 
Softening of the affected muscles sometimes accompanies paralysis, espe- 

* [Mr. Paget believes that the disease which most English writers have described as 
Mollities Ossium is really a fatty degeneration of those bones. Mr. Hunter's description of 
a softened humerus confirms this opinion. He says, "the component parts of the bone were 
totally altered, the structure b«ing very different from other bones, and wholly composed of 
a new substance resembling a species of fatty tumor, and giving the appearance of spongy 
bone, deprived of its earth, and soaked in soft fat." (a) Mr. Paget has, from no specimen of 
mollities ossium which has come under his notice, been able to agree to the general notion of 
the nature of the disease, which refers it to the removal of the earthy matter of bone, and 
the reduction of any part of the skeleton to its cartilaginous basis. He has found, as the 
chief features of the structural change, softness and brittleness of the bones, with the pre- 
sence of a large quantity of adipose matter, resulting apparently from the conversion of the 
cartilaginous basis into fat. Flexibility and tenacity would rather be the conditions, if the 
calcareous matter were deficient, and the cartilaginous basis normal. Rokitansky has de- 
scribed under the name of osteomalacia, malosteon, rachitismus adultorum, an affection of 
the bones of the trunk, occurring especially after childbirth, which coincides in its character 
with the ordinary ideas respecting mollities ossium. Similar cases of this kind have been 
published recently by Mr. Dalrymple and Dr. Bence Jones. So that, as Mr. Paget observes, 
there are probably two diseases included in the name of mollities ossium— the fatty degene- 
ration, and the simple softening of bones (6). — C] 

(a) Catalogue of the Pathological Museum of the College of Surgeons, vol ii. p. 28. 
(6) Paget's Lectures, &c. } ioc. cit. 



284 



STRUCTURAL DISEASES. 



cially that from lead. In a few instances, partial softening, like atrophy, 
follows inflammation, and is to be ascribed to the obstruction of vessels 
which that affection has produced. Thus softening of portions of the 
brain occasionally follows meningitis ; softening of the heart succeeds to 
pericarditis; softening of the stomach and intestines occurs after some 
kinds of gastro-enteritis ; softening of the articular cartilages sometimes 
succeeds to their inflammation. 

In all cases of partial softening, although the chief cause is local, yet 
a non-fibrinous or aplastic condition of the blood materially assists in pro- 
moting this result; and it is a serious question whether the continuance 
of antiphlogistic measures and abstinence does not occasionally promote 
this consequence of the changes of inflammation. Some of the most dis- 
tinct cases of softening of the heart and brain that I have met with, have 
been those in which the patients have been long kept in a reduced state, 
for fear of return of inflammation of these organs. 

539. Induration and softening being opposites of each other, although 
sometimes preceded by similar causes, require in some degree parallel 
modes of treatment, but in an opposite way. Induration consisting of 
condensed hypertrophy, and often arising from prolonged determination, 
may be counteracted by partial antiphlogistic measures, especially those 
tending to remove obstructions and deposits (§§ 511, 515). Thus mer- 
cury and iodine, externally and internally used, and alkaline saline 
medicines, are supposed to have some power in discussing hard swell- 
ings ; and setons, issues, or suppurating counter-irritants, which draw 
away blood and nutriment from the indurated part, may be found in 
some cases useful. But extreme antiphlogistic or reducing measures 
are not indicated (§ 218), inasmuch as induration itself implies a degraded 
kind of the nutritive material (§ 537), and does not result from acute or 
sthenic inflammation. 

540. In cases of softening that are not specific (§ 538), the indications 
of treatment are to restore a more fibrinous or plastic state of the blood 
generally, and to improve the circulation in the atrophied part. In fevers 
and cachectic states, where the softening is general, the first is the chief 
indication, and some of the means of fulfilling it, have been already 
noticed (§ 216). Besides nourishing food, and agents which improve 
the digestion and circulation, tonics and stimulants are often useful. 
How far the operation of mineral acids, bark, and other tonics, depends 
on their astringent or bracing influence on the animal fibre, we cannot 
undertake to determine; but after fevers, and in cachectic states, they do 
appear to improve the substance and firmness of the solids, in a way 
more direct than by merely exciting the circulation, and ameliorating the 
condition of the digestive organs. So, too, the operation of stimulants, 
both local and general, probably goes beyond that of accelerating the 
circulation, and determining blood to parts where it is ill supplied: it 
probably also increases the production of fibrin and cell-germs from the 
albumen of the blood, just as we see this to result from the application 
of stimulants before they cause inflammation (§§ 294, 415). The relief 
sometimes afforded to the symptoms of softening of the brain and heart, 
after all inflammation has ceased, by mild stimulants, tonics, and a 
moderately nourishing diet, is too little known to those who have always 



TRANSFORMATION OF TEXTURES. 



285 



the dread of inflammation before their eyes, and who yet forget that a 
chief evil of inflammation is the injury it inflicts on function and struc- 
ture, which injury often lasts when the inflammation is gone or is of 
trivial amount. The beneficial effect of nourishing diet and stimulant 
applications on soft flabby ulcers, is another illustration in favor of this 
kind of treatment in cases of internal disease, where the general weak- 
ness, apyrexia, pallidity, and muscular emaciation, much preponderate 
over the symptoms of local irritation. A chief part of the benefit arising 
from the use of stimulants and tonics, may be fairly traced to their pro- 
moting the healthy formation of blood, and an increased vigor of circu- 
lation ; but there are some agents which seem to augment the plasticity 
of the blood, and which have no remarkable tonic powers. I allude to 
nitric acid, nitro-muriatic acid, and chlorate of potass, the power of which, 
in promoting the healing of cachectic or spreading ulcers, is very remark- 
able ; and I have obtained much advantage from the use of these medi- 
cines in various cachectic states following prolonged acute disease or 
habits of intemperance. It seems most probable that these agents are 
chiefly useful in supplying to the blood, the oxygen necessary for the 
formation of fibrin (§ 211) or deutoxide of protein; the respiration in its 
weakened state being inadequate to furnish a due amount. On a simi- 
lar principle, the purest air, and such exercise or friction as may tend 
to make the respiration and circulation more effective, are beneficial in 
these cachectic states. 

541. The treatment of the specific example of softening found in the 
bones, is not well understood. The circumstances which promote or 
impede the deposition of phosphate of lime in the bones, are not clearly 
known ; but measures of a tonic kind, with appropriate nourishing diet, 
have been found distinctly useful in rickets in children. The mollities 
ossium of adults, is a still more obscure and intractable affection. The 
formation of callus at the ends of fractured bone, and the completion of 
the ossific process in it, are promoted by generous diet and tonics. 



SECTION V. 

TRANSFORMATION AND DEGENERATION OF TEXTURES. 

542. When one elementary texture, as muscle, is replaced by another, 
as fibrous, it is said to be transformed. The term degeneration is also 
generally applicable to this change ; for the new texture substituted for 
the old is most commonly lower in vital properties. The chief excep- 
tions are in the case of skin being transformed into mucous membrane, 
when by anchylosis of a joint, an external surface is brought almost to 
the condition of an internal; and the converse case of transformation of 
mucous membrane into skin, as in long prolapsed uterus. In these in- 
stances, the changes appear to arise from the physical condition in which 
the membrane is placed: the exudation corpuscles remaining soft and 
moist, and becoming epithelium scales and mucous globules in one case, 
and drying into epidermis in the other. 



286 



STRUCTURAL DISEASES. 



Muscle is sometimes transformed into fibrous or fibro-cellular texture, 
in some cases after inflammation of contiguous parts. Loss of substance 
in muscles from wounds or ulcers is generally replaced by a similar 
fibro-cellular texture, and never by new muscles. 

543. Animal textures are liable to various kinds of degeneration; four 
of which maybe particularly specified as having very distinctive physical 
and chemical characters ; namely, the fibrous, the granular, the fatty, 
and the osseous or calcareous. All present the characters of deterioration 
or degradation in the scale of living textures, which the term degenera- 
tion is meant to imply ; and they do so in degrees corresponding with 
the order in which we here arrange them. In chemical composition, 
and in a fainter degree in their physical condition, they analogically 
present a successive descent from animal to vegetable and mineral sub- 
stances. 

Fibrous degeneration chiefly affects muscular structures, especially 
when inflammation has existed long in or near them. Thus parts of the 
muscular fibres of the heart have been found converted into a dense 
fibrous tissue after endocarditis and pericarditis: those of the limbs after 
prolonged fascial rheumatism : those of the intercostal muscles and dia- 
phragm in chronic pleurisy. Age works a similar change, as displayed 
in the tough and sinewy condition, with wasting of size, of the muscles 
of old animals (§ 48). The fibrous tissue thus developed resembles that 
existing naturally in the tendinous and fibrous structures of the body, 
consisting of closely knit bundles of fibres, but with a scantier distribu- 
tion of nuclei, and very few blood-vessels pervading them. The fibres 
are usually also coarser, and here and there present granular irregulari- 
ties. They often tend in time to degenerate into the other forms of 
degraded animal substance, the granular, fatty, and osseous. In che- 
mical composition, they belong to the group of gelatigenous tissues. 
Several parenchymatous organs, the spleen, the liver, the kidneys, and 
the lungs, sometimes present a change which seems to amount to a fibrous 
degeneration, a dense filamentous tissue pervading and more or less 
superseding their natural structures ; but as in all these instances there 
is a great increase in the density of the organ, it is more correct to view 
the new fibrous material in the light of an interstitial deposit, than as a 
transformation of the proper textures. This will be considered under 
another head. 

544. Granular degeneration, as commonly met with in organs, is, 
like that just noticed, the result of a cacoplasac deposit effused in the 
interstices of a texture, and exhibiting more or less of a granular com- 
position. But this same appearance is sometimes exhibited in textures 
under the deteriorating influence of mal-nutrition, chronic inflammation, 
and old age, without any augmentation of substance. We have just 
noticed that morbid fibrous tissues sometimes tend to this result. The 
same change may invade natural fibrous and elastic tissues, especially 
of the vascular system, impairing their cohesion and transparency, and 
rendering them liable to extension, laceration, and rupture ; or consti- 
tuting the first stage of the further degeneration into fatty or calcareous 
matter. Under the microscope, the structure presents a remarkable in- 



DEGENERATION — GRANULAR, FATTY. 



287 



crease of aggregated granules, with a corresponding diminution of the 
fibrous or filamentous tissue. The granules are not highly refractive, 
and there are no free oil globules ; in this respect it differs from fatty 
degeneration; neither is it so opaque or fragile as the true fatty atheroma. 
It is probably a condition intermediate between fibrous and fatty or 
osseous degeneration ; and I have repeatedly found it in an artery which 
presented both these changes. Its chemical composition is uncertain ; 
but probably it is either gelatigenous or albuminous, with an increase of 
fat in the form of molecules. Cacoplastic deposits and recent lymph 
sometimes degenerate in this mode. 

[Mr. Paget has recently described* a pathological condition of the 
heart, not previously recognized, under the name of "granular degenera- 
tion" of its muscular tissue. In this there is neither any evident depo- 
sition of fat, nor is there that mottled appearance which indicates com- 
plete local fatty degeneration in spots or lines of the muscular tissue. 
"The whole organ has its natural shape, size, and general external 
appearance; but it feels soft, doughy, inelastic, unresisting, and may be 
moulded and doubled up like a heart beginning to decompose long after 
death; it seems never to have been in the state of rigor mortis. These 
appearances are more manifest when a section is made through the wall 
of the left ventricle. Then if the wall be only partly cut through, the 
rest of it may be very easily torn, as if with separation of fibres that 
only stick together ; and the cut surface of the wall looks, as it were, 
lobulated and granular, almost like a piece of soft conglomerate gland, 
— an appearance which is yet more striking when observed with a simple 
lens of about half an inch focus. In color, it has not on its surface, 
much less on its section, the full ruddy brown of healthy heart, a color 
approaching that of the strong voluntary muscle ; but is, for the most 
part, of a duller, dirtier, lighter brown, in some parts gradually blending 
with irregular marks or blotches of a paler fawn color." When micro- 
scopically examined, the fibres are found to show a remarkable tend- 
ency to transverse cleavage ; very minute oil-particles are seen in their 
interior; and no nuclei are found lying among them. In three cases 
in w 7 hich Mr. Paget has observed this form of fatty degeneration, death 
was very sudden, and was not preceded by any symptoms indicative 
of imperfect action of the heart. It may proceed silently and gradu- 
ally, undermining the power of the entire heart, yet not rendering 
itself apparent by any functional change during the ordinary events of 
calm and quiet life ; but the individuals thus affected are wholly unable 
to resist the storm of a sickness, or the shock of an accident or an ope- 
ration. It is very probable that many cases of sudden death, not other- 
wise accounted for, have been due to this cause ; for a structural change 
of this kind may have advanced so far as to be sufficient to destroy life, 
without being perceptible to any but a very careful and practised ex- 
aminer. — C] 

545. Fatty degeneration was long since described by Laennec as af- 
fecting the muscles, liver, and some other structures. It is to be dis- 



* Lectures, &c, loc. cit. 



288 



STRUCTURAL DISEASES. 



tinguished from fatty accumulation, which is hypertrophy of the natural 
adipose texture or fat cells, and which may by its bulk press on textures, 
and cause their wasting. True fatty degeneration consists in the forma- 
tion of fat in the proper tissue of the part; thus in fatty degeneration of 
muscles, the fibres themselves become pale in patches or spots, and under 
the microscope exhibit fatty globules or crystals within the sarcolemma; 
and as the change increases, the color and consistence of the muscle are 
impaired, and its power proportionately weakened. This change has 
been found in the heart and in some voluntary muscles under circum- 
stances somewhat like those which promote the fibrous degeneration of 
the same textures ; but apparently in connection with still weaker con- 
stitutional powers, and other evidences of mal-nutrition. In the same 
cases, as well as in others, the arteries exhibit the atheromatous patches 
which Mr. Gulliver has proved to consist of fatty matter, which appears 
to be partly formed at the expense of the middle coat, and partly depo- 
sited in a granular and globular form under the inner lining. 

Fatty degeneration of the liver is characterized by a pale opaque ap- 
pearance of the viscus, its soft greasy consistence, its low specific gra- 
vity (sometimes floating in water), and by its greasing paper when heated 
upon it. Mr. Bowman pointed out that the liver cells naturally contain 
a considerable proportion of oil globules: and he suggested that fatty 
degeneration might depend on an increase of this normal constituent, so 
great as to press on, and cause the atrophy of the other tissues. It has 
been surmised that this fat is the bile in the process of its formation by 
the secreting cells; and that its increase in phthisis is due to the addi- 
tional task thrown on the liver to excrete from the system the hydrocarbon, 
which the lungs in their disabled state cannot remove. If this were true, 
fatty degeneration of the liver would occur more constantly in phthisis 
and other diseases of the lungs than we find to be the case. I have met 
with it chiefly in females in whom emaciation has proceeded with great 
rapidity ; and I should rather ascribe it to the arrest of the fatty matter 
which is taken into the blood during the rapid decay of the textures, and 
conveyed to the liver as the proper excreting organ of such materials. 
It is also possible that the fatty matter which is formed in tubercle, 
during its process of maturation and softening, may be conveyed in to 
the circulation, and contribute to this change in the liver. 

[Mr. Paget also dissents from the explanation of the disease generally 
admitted. He gives the following reasons against it. — 1. The connec- 
tion between fatty liver and disease of the lungs is not general. In 
many w T ho die phthisical, the liver is healthy. — 2. There is no evidence 
derived from examination of the feces, that the fatty liver does secrete 
an unusual quantity of carbon and hydrogen. — 3. If the carbon and 
hydrogen, supposed to be formed in extra quantity in the liver, be not 
in the feces, then the lungs would only be damaged by the excessive 
formation of those elements in the liver; the function of the liver, in 
warm-blooded animals after birth, being chiefly preparatory to that of 
the lungs. — And 4. All the conditions of the fatty liver show that it is 
an inactive organ, one which is discharging less than its ordinary func- 
tion, and the less, the more general the fatty degeneration of its cells. 
This is indicated by the analogy of all fatty degenerations, the absence 



FATTY DEGENERATION. 



289 



of nuclei in the fatty cells, the absence of all appearance of the coloring 
matter of the bile in them, the large size of the liver (indicating a tardy 
or obstructed removal of its cells), the paleness and defective supply of 
blood, and the frequent coincidence of other morbid changes, such as 
would naturally hinder the proper activity of the organ. We have, too, 
a corresponding change in the kidney, presently to be noticed, with no 
excretion of fatty matter, and a diminished excretion of the proper ma- 
terials of the urine. — C] 

But fatty transformation occurs in other organs and tissues so com- 
monly as to show that it must arise from some chemical tendency in 
animal substances, independent of the function of any particular organ. 
Thus we have already (§§ 223, 258, 538) noticed several instances in 
which fat globules are found in increased numbers in various organs of 
the body, without any marked development of the common adipose tex- 
tures. This has frequently occurred in the bodies of persons who have 
been habitually intemperate, generally with more or less disease in the 
liver, with or without jaundice; but I have met with a few such cases 
in cachectic subjects who have not been addicted to excesses, and in 
these most commonly the urine has been albuminous, and the kidneys 
have exhibited more or less of the degeneration described by Dr. Bright. 
In all these examples, all the viscera which I have examined have pre- 
sented an unusual predominance of oil globules, with some degree of 
softening and opaque yellowish pallidity, common to ill-nourished tissues ; 
the liver, spleen, kidneys, and even the muscles, having a dingy red, or 
yellowish brick hue, instead of their proper colors. The increase of oil 
globules in the epithelium cells of the kidney has been particularly 
noticed by Dr. George Johnson, who considers it to be the primary pa- 
thological change in B right's disease of the kidney, corresponding w T ith 
fatty degeneration of the liver; and he ascribes the impaired function 
and wasted structure of the organ to this accumulation of fat. But 
although I admit the presence of numerous fat globules in certain forms 
of degenerated kidney (indeed, I had described it before Dr. Johnson 
made his researches), I have never seen in the kidney anything at all 
approaching to the condition of the fat liver, in which both cells and in- 
terstitial textures are completely glutted with oil globules. 

In fact, the same increase of fat globules which, in these cases, is no- 
ticed in the kidney, is found in other textures, and is the result of a mal- 
nutrition which tends to convert other animal substances into fatty matter. 
A similar tendency is manifest in the products of inflammation and other 
deposits. Thus the opaque exudation corpuscles found by Mr. Gulliver 
in great abundance in the lungs affected with low inflammation, (espe- 
cially chronic,) and in gangrene, were ascertained by Dr. Davy to con- 
sist chiefly of olein and margarin. The pus of old abscesses, mature 
and softened tubercle, fibrinous vegetations on the valves of the heart, 
and the softened fibrin found in blood-vessels, or on serous surfaces long 
inflamed, also contain a very large proportion of fatty matter in a solid 
crystalline, granular, or a liquid form. The following extract from Mr. 
Gulliver's notes to Hew r son's works bears on the same point. "In Dr. 
Benjamin Babington's observations, the specific gravity of the milk-like 
serum of the blood, appeared to be so regularly reduced, as to lead him 
19 



290 



STRUCTURAL DISEASES. 



to believe that the oil exists at the expense of the albumen. There are 
some facts in favor of the idea that albumen may be converted into oil. 
The rapid disappearance of the matter of the curd of perfectly fresh sal- 
mon, with the subsequent more oily state of this fish, maybe owing to a 
conversion of this kind, according to the conjecture of Sir Humphry Davy, 
as I have learnt from Dr. Davy. I have observed that the oil in the liver 
of several fishes increases after death, probably in connection with in- 
cipient putrefaction ; and Dr. Davy informs me that in the liver of the 
cod, after it had been kept in a damp place for twenty-five days, he found 
a small increase of oil with the formation of carbonic acid and ammonia 
at the same time." — p. 86, note. 

But there is no chemical fact, which throw T S so much light on fatty 
degeneration, as that of the formation of adipocire from animal flesh when 
kept moist without access of air. I directed attention to this analogy in 
the former edition of this work; and Dr. Alison, in his recent essay on 
"Vital Affinities," [Trans, of Royal Soc. of Edinburgh, 1847,) proposes 
a formula by which the conversion of albumen and water into fat and 
carbonate of ammonia, may be explained. 

The circumstances under which fatty degeneration takes place, much 
favor the view that I have given of its being the result of chemical affi- 
nities prevailing, as in the examples above cited.* As a general disorder, 
or affecting many organs at once, it occurs in connection with a feeble 
circulation and low respiratory powers; and is favored by circumstances 
which increase the hydrocarbon of the blood, wdiether they be the habitual 
indulgence in alcoholic stimulants and the like; or the imperfect removal 
of biliary matter from the system. An increase of fat, especially of cho- 
lesterin, has been observed in the blood of aged persons. Fatty dege- 
neration affecting a particular organ (except in the peculiar case of the 
liver), is commonly a result of previous disease impairing the freedom of 
circulation through it, and often leaving a granular or other cacoplastic 
deposit in its interstices, which, not becoming fully organized, nor receiv- 

* [Mr. Paget contends (a) that what is ordinarily called "fatty degeneration," is a form of 
atrophy, and for these reasons: — 1. The frequent coincidence of fatty degeneration with, 
emaciation, or dimimition of size of the part. 2. The existence of fatty degeneration under 
circumstances which, in other instances, give rise to simple wasting of the same part. 3. The 
frequent occurrence of fatty degeneration, with senile atrophy. Tt is generally agreed that 
the nucleus is the active agent in the changes which the cell effects. Now in all Mr. Paget's 
observations on atrophied parts, he found the nucleus absent or imperfect; and he has so 
often observed this change in fatty degenerations of the liver, kidneys, and muscles, that he 
asserts the general fact, that when the accumulation of fat exceeds a very small amount, the 
nucleus of the cell, or other elementary structure containing it, is pale and indistinct; and 
when the fat is abundantly collected, it disappears completely. He does not regard the fatty 
matter, in such cases, in the light of a new deposit, but as one of the products of the spon- 
taneous transformation of the tissues at the end of their proper periods of vigorous existence; 
so that this condition represents the state of a tissue remaining unrepaired after it has fallen 
into the ordinary course of degeneration. The formation of butyric acid, during the decom- 
position of fibrin in the open air, according to Wurtz's observation, and the conversion into 
adipocire of nearly all the soft tissues of the body, under peculiar circumstances, are argu- 
ments in favor of this view. In muscular fibres, the fat particles are frequently found ar- 
ranged in the same manner as the proper constituents of the fibrils — sometimes in trans- 
verse, aricC sometimes in longitudinal rows. From Rokitansky's observations it is evident, 
that fat is one of the products of the spontaneous transformation of the higher proteine com- 
pounds. — C] 



(a) Lectures, loc cit. 



CALCAREOUS DEGENERATION. 



291 



ing the renovating and oxidating influence of the circulating blood, gra- 
dually passes into a fatty condition, the lowest in the animal scale, and, 
in its not possessing azote, approaching to the plurality of vegetable mat- 
ters. The same changes may result more gradually from the failing cir- 
culation and respiration which mark advancing age (§ 48) ; and will be 
accelerated in any texture or organ, the structure of which has been in- 
jured by previous disease, accident, or disuse. 

Under whatever circumstances the fatty transformation occurs, it is 
obviously a process of degeneration, or degradation to a very low scale 
of animal or even vegetable life; (its occurrence in gangrene is a strik- 
ing illustration of this point:) and both the vital and physical properties 
of the organs which it invades, become lowered and otherwise injured. 
Thus muscles so degenerated lose much of their contractile power, and 
if subjected to distention, as in the heart, become dilated, and may be 
ruptured. The tonic and elastic fibres of arteries also suffer in their 
spring-like properties, and may yield in pouches or become lacerated, 
or in process of time, petrified. Glands and secreting structures lose 
much of their secernent activity, and their cells, vessels and ducts may 
be clogged or deranged by their fatty contents, especially when these 
assume the solid form. Parenchymata and interstitial tissues suffer in 
their properties of softness and cohesion, and in the freedom of their 
circulation, and become liable to the further changes of disintegration, 
and calcareous deposition, which is the last kind of degeneration to be 
noticed. 

546. Calcareous or osseous degeneration approximates the structure 
which it invades to the character of a mineral, and may be properly 
designated by the term petrifaction. The tissues most liable to the 
change are those low in the scale of organization, yet constantly moist- 
ened by the blood liquor, such as cartilage, fibro-cartilage, and fibrous 
tissue, and similar structures resulting from disease. This morbid ossi- 
fication has been commonly compared to the natural process of the forma- 
tion of bone ; but it resembles that process no further than in the depo- 
sition of solid phosphate of lime in the interstices of the tissue ; and 
where that tissue approaches to bone in its structure, the result may 
resemble bone, as in the case of ossified cartilages: but in ossified fibrous 
tissue and membranes, as in arteries and the valves of the heart, the 
calcareous matter forms plates and masses which have no affinity to the 
structure of bone. In fact, the most complete specimens of petrifaction 
gradually supervene in the deposits of aplastic fibrin in lymphatic glands, 
in the lungs, on the surface of serous membranes, and on and under the 
lining membrane of arteries — which, if they escape the processes of fatty 
degeneration and softening, are ultimately converted into masses or plates 
of calculous or stony matter, in which there may be little or no animal 
substance. This process is, therefore, to be viewed as almost entirely 
chemical, consisting in the concretion and accumulation of a calcareous 
salt, phosphate of lime, in the debris of animal matter. It is uncertain 
whether this calcareous matter is the insoluble residue of a successive 
series of processes of deposition and absorption ; or the result of a chemi- 
cal attraction of degenerating albumen for the phosphate of lime in the 
adjoining fluids ; but the latter 'seems the more probable notion, arid is 



292 



STRUCTURAL DISEASES. 



strengthened by the fact that a similar petrifaction sometimes occurs in 
loose cartilages in joints, and in detached concretions in veins (phebolites). 

The petrifactive process is essentially a slow one ; and, as a sponta- 
neous change, occurs most in advanced age : but, like other degenerations, 
may be induced and accelerated by inflammation, especially of a chronic 
kind. Thus the cartilages of the ribs, and of the air-tubes, and many 
of the arteries, are generally more or less ossified in old people : they are 
frequently found in the same state in earlier life, after repeated or pro- 
longed attacks of inflammation in the adjoining parts. 

It is scarcely necessary to point out the various modes in which morbid 
ossification injures the structure and function of parts, by rendering them 
rigid, inflexible, inextensible, inelastic, and therefore brittle and ob- 
structive. It is this process in particular which stiffens the gait, shortens 
the breath, and weakens the circulation of advanced age (§ 48), and 
renders the frame unfit to bear shocks or sudden changes, which it is 
capable of resisting when possessed of the pliancy, elasticity, and vary- 
ing powers of earlier life. So a similar change induced by disease in a 
particular apparatus, as that of the respiration or circulation, reduces 
that apparatus to the limited capacity of decrepitude: thus a young or 
middle-aged person with asthmatic breath or crippled circulation from 
such cause, is so far prematurely old, and encounters more suffering and 
danger in proportion as his other functions and feelings are active and 
impressible, and tempt him to trials which the straitened organs are unable 
to bear. Hence in connection with ossified bronchial tubes, there may 
occur occasional attacks of spasmodic asthma and pulmonary congestion ; 
and incident on ossified valves or arteries, there may supervene painful 
and dangerous paroxysms of angina — from all of which the equally, but 
more completely or uniformly, petrified old man may remain free so long 
as he is kept in a state of vegetable or almost mineral quiescence. These 
considerations suggest important points of practical application. 

Treatment of Degenerations. 

547. It may readily be inferred from the preceding remarks, that, if 
any means are capable of resisting the progress of degeneration of struc- 
tures, they are those which tend to sustain the vitality of the frame, and 
to preserve the organic functions in an equally balanced activity. Hygi- 
enic influences, such as pure air, regular exercise, and friction of the 
surface, baths warm or cold, as the system may bear them, nutritious 
and carefully proportioned food (§§ 60, 219), deserve the first mention 
among these curative or tardative measures. Of medicinal agents, those 
generally denominated tonics may be of some little utility, such as pre- 
parations of iron, bark, arsenic, and mineral acids ; but as in most 
cachectic states the secretions are commonly more or less defective, 
these medicines are not well borne unless combined with others which 
obviate this defect, such as alterative aperients, and salines; and the 
combination is presented in a convenient, and, through custom, in an 
attractive form, in the various chalybeate and saline mineral waters of 
the most frequented spas. These are the favorite resorts of persons of 
" worn out constitution," who are in truth the subjects more or less of 



TREATMENT OF DEGENERATIONS. 



293 



degenerative changes of structure, and who find in the regular routine 
of healthier habits, as well as in the virtues of the mineral waters and 
baths of these places, a degree of relief and returning strength which 
they fail to obtain under medicinal treatment at home. 

Partial degenerations we have found to be promoted by a disordered 
state of the circulation of the part, as from congestion or inflammation 
in a low form ; and the treatment must comprise the removal or counter- 
action of such local disorder, by such gentle means, chiefly topical, as 
may not compromise the constitutional powers of the subject. There 
are individual remedies which claim a notice as applicable to peculiar 
kinds of degeneration. 

548. Fibrous and granular degenerations, as they are commonly par- 
tial, and result from continued or repeated inflammations, may be in 
some measure retarded by the less weakening forms of antiphlogistic 
remedies, such as counter-irritation, local bathing, and friction with sti- 
mulant liniments, and the external and internal use of iodine in some of 
its combinations and alkalies. These means are serviceable in restoring 
power to muscles injured by rheumatic and other inflammation, which 
may end in fibrous degeneration. Mercury is generally too weakening 
as an internal remedy, but in such cases it is sometimes useful externally. 

The more peculiar chemical nature of fat, and its special relation to 
particular organs, the lungs and the liver, suggest to us means which 
may tend to prevent its accumulation in the system, and substitution for 
the more animalized textures. The rigid exclusion of all fatty articles 
of diet and the sparing use of saccharine matter and fermented liquors, 
and the selection of lean meats, bread, and succulent vegetables for food, 
with a fit proportion of salt and other condiments ; the promotion of free 
circulation and respiration, by regular exercise in pure air, with occa- 
sional bathing and friction to promote the healthy action of the skin ; 
and the due regulation of the bowels, aided, if necessary, by medicines 
w 7 hich augment the secretion of bile ; such are the chief means to be 
opposed to the adipose cachexia. The tonic remedies recommended in 
degenerations in general, are also distinctly serviceable here ; and I have 
known several examples of temporary benefit from them, in cases which 
ultimately proved to include fatty degeneration of the heart. In some 
instances, the nitric or nitro-muriatic acid has been found beneficial ; in 
others, ammonia; and one is tempted to attach some meaning to the 
peculiar composition of these agents — as opposed to that of fat — the acids 
affording oxygen which may remove a part of the superfluous fat; and 
both these and ammonia supplying azote which may contribute to the 
formation of a more animalized plasma. The disposition which the 
fatty material has to assume the solid form in these degenerations, sug- 
gests an advantage likely to arise from the use of some solvent which 
may liquefy the fatty concretions ; and I know of nothing so likely to 
possess this quality as the liquid part of cod-liver oil, the utility of which 
in removing deposits which abound in fat, will shortly come under our 
notice. 

We know little of means calculated to counteract the calcareous dege- 
neration, further than those before recommended with the common ob- 
ject of sustaining vital energies, and preventing the nutrition of parts 



294 



STRUCTURAL DISEASES. 



from being perverted by inflammatory or congestive disorder. Hydro- 
chloric acid exerts a remarkably solvent power on salts of lime; in some 
cases, mollities ossium has been supposed to have arisen from an exces- 
sive use of salt, but it is quite uncertain whether such a property would 
reach to the morbid deposition of phosphate of lime in textures. We 
have already given some hints on the expediency of limiting the vic- 
tims of ossification to a restricted sphere of excitement and exertion 
(§ 546). 



SECTION VI. 

DEPOSITS IN OR UPON TEXTURES. 

548. I apply the term deposits to matters which result from an over- 
flow of the nutritive material beyond what is necessary to nourish the 
textures themselves. The structural lesions, hitherto considered, are 
alterations of the textures themselves ; deposits are new matters added 
to the textures. The basis of all deposits is the fibrinous matter of the 
blood ; and in the products of inflammation (§§ 450—3) we have de* 
scribed its varieties in relation to its plasticity, or capability of organiza- 
tion. The same division is applicable to deposits which take place 
independently of inflammation, as results of an overflow of the material 
of reparatory nutrition, and thus w T e have euplastic, cacoplastic and aplas- 
tic deposits from perverted nutrition. The history already given of 
these, as they result from inflammation, will supersede the necessity of 
much detail now, and it will suffice to advert to the circumstances in 
which they arise independently of inflammation. 

Euplastic Deposits — Cicatrices. 

549. When a living part is cut or wounded, the breach may be 
repaired by three modes : — 1. By the growth of the adjoining parts, or 
walls of the wound ; 2. By the medium of coagulable lymph, which 
becomes organized, and forms a cicatrix, or bond of union; and 3, by 
granulations and lymph together. The latter mode being necessarily 
attended with inflammation, is excluded from notice here; but the other 
two, as Dr. Macartney has shown, may occur independently of obvious 
inflammation, and are more perfect without it. To these, however, a 
certain amount of determination of well-fibrinized blood, which supplies 
the plastic material, is necessary; for the process of reparation, in all its 
varieties, is always effected from this source. 

The first of these processes occurs chiefly in very small breaches of 
the surface, as in fine punctures and incisions, and in larger wounds 
under circumstances which prevent irritation and inflammation. In 
these instances, there may be no increased redness or swelling, and no 
obvious lymph effused, but the sides of the wound gradually approximate 
by an increased production of the textures of the part ?/ until the breach 



DEPOSITS, EUPLASTIC — CICATRICES. 



295 



is repaired.* In this way, wounds heal spontaneously when covered 
with a hard clot of blood ; or under soothing applications which exclude 
the air, and at the same time exercise a moderate and equal pressure on 
the part. " It might be anticipated, that, as this mode of reparation 
bears so strong a resemblance to the natural formation and development 
of parts, it is the slowest mode ; but this is of little account when com- 
pared with its great advantages in being unattended with pain, inflam- 
mation and constitutional sympathy, and leaving behind it the best de- 
scription of cicatrix."! In the case of large burns on the trunk of 
children, the difference between the two modes of reparation will fre- 
quently be that of life and death, for it often happens that the patient 
sinks under the great constitutional disturbance occasioned by a large 
suppurating surface, although he has survived the immediate shock of 
the injury {Carpenter 's Physiology, [p. 602, Am. ed.]). 

550. The other mode of reparation is that long denominated by sur- 
geons union by the first intention, in which the sides of a wound heal by 
the organization of coagulable lymph, or, more rarely, of a clot of blood, 
which, when complete, forms a cicatrix. The following description of 
the process is taken from Dr. Carpenter's " Human Physiology," 3d 
edition, 1846, p. 600 [Am. ed.]. " This mode of union is ordinarily 
considered by British surgeons to be the result of an adhesive inflammation. 
In so regarding it, they conceive that they are following out the views 
of Hunter; but he expressly states that wounds may heal without any 
pain or constitutional disturbance, the re-union proceeding ' as if nothing 
had happened;' so that he in effect admits, that reparation of this kind 
takes place without inflammation. It is well known, that if a slight 
wound, which is thus healing, be provoked to an increased degree of in- 
flammation, its progress is interrupted, and all the means which the sur- 
geon employs to promote union, are such as tend to prevent the accession 
of this state. The doctrine that the effusion of lymph for the reparation of 
the tissues is not to be regarded as necessarily a result of the inflamma- 
tory process, is not so novel as its opponents have regarded it, since it 
has been maintained by many eminent observers, even from the earliest 
times.j: The only case in which the occurrence of inflammation can be 
regarded as salutary, is that in which there is a deficiency of fibrin in 

* The following observation illustrates this process : — " I made a small pin-hole in a frog's 
web; the capillaries that were divided yielded no blood and became obstructed ; but the 
circulation continued, although sluggishly, in those adjoining, which were distant from the 
puncture the length of six or eight blood-discs. The next day, these vessels were no nearer ; 
but the circulation in them was more active, and the hole was partly filled up 5 and on the 
third day, it was completely so, yet no moving blood could be seen nearer to it. On the fifth 
day, the distribution of visible vessels was not altered, but the matter with which the hole 
was filled had contracted and become opaque, so that the adjoining vessels were drawn 
nearer together, and the opacity prevented my seeing whether any passed through the cica- 
trix." — Gulstonian Lectures, Med. Gaz., July 30, 1841, p. 721. 

j- Dr. Macartney, Treatise on Inflammation p. 178. 

J Although I admit that inflammation, in its pronounced form, is not essential to this re- 
paration, yet there seems to be a close approximation to this process. When a frog's web is 
cut or pricked, the vessels adjoining the wound are immediately obstructed by coagulated 
blood; but in a few seconds, those adjoining them become enlarged, and receive an increased 
current, and it is this determination of blood towards vessels which are obstructed, which 
causes an increased transudation of the plasma of the blood (§ 419). If this do not amount 
to inflammation, it differs from it only in degree. 



296 



STRUCTURAL DISEASES. 



the blood, causing a deficient organizability of the lymph," (or, rather, 
a deficiency of lymph itself.) "It has been seen (§ 438) that the 
amount of fibrin is rapidly increased by inflammation ; and the surgeon 
well knows that a wound with pale flabby edges, in a depressed state of 
the system, will not heal until some degree of inflammation has com- 
menced. 

"When the liquor sanguinis, known as coagulable lymph, is effused 
between the two edges of a wound, or upon the surface of a membrane 
lining a closed sac, the following appears to be the history of its organi- 
zation. The new matter which is poured out in a fluid state, and which 
seems to have been subjected to the peculiar influence of the colorless 
corpuscles that rapidly collect in large numbers at the injured spot, 
undergoes a coagulation resembling that of the blood ; the serum, being 
set free by the concretion of the fibrin, is absorbed ; and the fibrinous 
coagulum speedily attains an almost membranous density. If examined 
with a microscope at the commencement of the process of organization, 
it is seen to contain a large number of cells, which sometimes closely 
resemble the colorless corpuscles of the blood, and in other instances, 
(especially where there has been active inflammation,) present greater 
similarity to pus corpuscles; these cells, which are known as exudation 
corpuscles, probably originate from the granules set free from the color- 
less corpuscles of the circulating blood, and exuded with the liquor san- 
guinis. In a short time, these corpuscles present the appearance of 
regular cells disposed in layers, and adhering together by an intermediate 
unorganized substance, bearing, in fact, a strong resemblance to the 
cells of tesselated epithelium. Some hours later, the mass exhibits an 
evidently fibrous character; and this is due to the further elaboration of 
the plastic material by the cells just mentioned. Between these fibres 
a considerable amount of unorganized substance (§ 523) yet remains, 
and they may be readily separated or torn in any direction. A vascular 
rete next makes its appearance in connection with the vessels of the 
subjacent surface; the first appearance of this network is in the form of 
transparent arborescent streaks, which push out extensions on all sides ; 
these encounter one another, and form a complete series of capillary 
reticulations, the distribution of which very nearly resembles that which 
has been seen in the villi of the intestines. From the observations 
of Mr. Travers, it appears that isolated globules enter these capillary 
tubes, and perform an oscillatory motion in them for some hours before 
any series of them passes into it ; so that we cannot regard the new 
channel as burrowed out by a string or file of red corpuscles, pushed out 
by vis a tergo from the nearest capillary, as some have maintained.* 
And he has further established two important facts in the history of the 
reparation of tissues, which correspond with the observation just cited : 
1, that the liquor sanguinis, first effused, is not sufficiently organizable to 

* There is nothing in Mr. Travers' observations which opposes the inference, which is 
drawn from numerous other facts, that the motion of the particles in these new channels is 
derived from the adjoining capillary vessels. The oscillatory movements are those of the 
pulsation of the heart, and are seen in many instances on the arterial side of obstructed 
capillaries. No current of blood, or file of red corpuscles, can pass until there is also a com- 
munication with the veins. — See note, p. 262. 



CACOPLASTIC AND APLASTIC DEPOSITS. 



297 



become an entirely new and permanent tissue, although adequate to 
aflbrd nutrition to the old, and to form a new tissue of temporary cha- 
racter : — and 2, that the generation of new tissues is preceded by the 
collection of a large number of white corpuscles in a nearly stationary 
condition in the blood-vessels immediately subjacent, and by the appear- 
ance of a large number of similar cells in the newly forming tissue, the 
two together constituting what Mr. T. has aptly called the lymph-bed 
of organization. This process appears to be conformable in all essential 
particulars with that which has been observed in the development of the 
toes of the larva of the w T aternewt and similar growths." 

Under some circumstances, the fibrin of coagulable blood has been 
found to become vascular, and more or less organized. Thus clots of 
blood in the blood-vessels have been injected, and those effused in the 
brain in apoplexy have been found pervaded with vessels (Ouveilhier) ; 
but the coloring matter does not appear to assist in the process: in fact, 
blood coagulated in or upon a wound generally comes off in a scab as 
soon as the wound is healed. In other instances, the presence of color- 
ing matter seems to retard or degrade rather than assist the plastic pro- 
cess (§ 454). 

551. The remedial measures by which the euplastic process is pro- 
moted in cases of injury, are treated of in surgical works. Their object 
is to promote such an amount of determination of blood, (whether this 
be called inflammation or not,) and such a plastic condition of the blood, 
as shall contribute to the effusion of a sufficient amount of healthy 
organizable lymph. Where inflammation rises too high, it causes too 
much effusion of the plasma, w 7 hich degenerates into aplastic pus glob- 
ules, and it destroys the adjoining textures: here it must be repressed 
by antiphlogistic measures. If the inflammation is too low(§ 477), or 
the determination of blood is wanting, then the plasma will be defective 
in quantity or organizability, and the wound will not heal, or will heal 
imperfectly. Here stimulant applications may be useful. Where the 
blood is too abundant in fibrin, the plasma thrown out will be too copious 
to admit of organization, and will consequently become purulent, and 
therefore aplastic. Here, blood-letting or evacuants, and low diet for a 
time, may be serviceable. Where the blood is deficient in fibrin, the 
wound will be flabby and the discharge ichorous or sanious, from want 
of the proper plasma: here, nourishing diet, tonics, and even stimulants, 
general and local, may be useful. The efficacy of a pure healthy 
atmosphere, which contributes to the due oxygenation of the blood, is 
sometimes very remarkable; and the salutary effect of nitric acid, used 
both externally and internally, is perhaps to be ascribed to the same 
principle (§ 216). Where the w r ound exhibits congestion more than de- 
termination of blood, and the plasma is organized into loose spongy or 
fungous masses projecting from the wound, astringent and stimulant ap- 
plications are beneficial. 

Cacoplastic and Aplastic Deposits. 

553. Under various circumstances which have been alluded to in the 
preceding remarks, wounds or ulcers may be repaired by lymph which 



298 



STRUCTURAL DISEASES. 



is cacoplastic, or defective in organizability ; and the cicatrix resulting 
from such imperfect reparation is lower in the scale of vitality than the 
texture in which it is produced. Thus in the skin, a tough, hard, opaque 
white fibro-cellular structure, constitutes the cicatrix; the seams formed 
on the healing of scrofulous sores sometimes exhibit this character; the 
blood not supplying a good plastic material. Or sometimes the cause 
of the degraded organization seems to be in the nature of the wound, or 
in a modification of the vessels of the part, or of their exudation, as in 
the scars which result from burns and scalds, and from some poisoned 
wounds. In these cases, the cicatrix is dense and thick, and tends fur- 
ther to contraction, which causes a puckering of the parts, and some- 
times great distortion of the integuments. Similar deposits have been 
noticed to result from chronic and scrofulous inflammation of internal 
parts (§§ 479, 485), and from congestion (§ 311), and to constitute the 
material of dense fibro-cellular and fibro-cartilaginous formations on and 
under serous and in cellular membranes ; the indurated interstitial struc- 
ture which characterizes cirrhosis,* and granular degeneration of the 
liver and kidneys, and old cicatrices and consolidations very commonly 
met with in the lungs. The opaque, tough thickening of the valves of 
the heart, often attended with corrugation, contraction, and rupture, and 
the similar change in the coats of arteries, appear to belong to the same 
class of deposits. 

554. The structure of these deposits deserves to be more fully inves- 
tigated. They appear to possess some organization, being composed of 
irregular cells and fibres, with more or less granular or amorphous solid 
matter to complete their substance (§ 424). They, however, exhibit 
various degrees of organization, some being vascular, and some not ; 
but they are all inferior to the structure with which they are connected, 
and to the euplastic deposits above described. Although rarely occur- 
ring in great abundance in an organ or structure, except from some 
hyperemia of that part, yet, in a small extent, cacoplastic deposits are 
to be met with in most subjects at all advanced in life, and more particu- 
larly those who have long suffered from ill health. The opaque thick- 
ening of the membranes investing the liver, spleen, lungs, heart, and 
brain, often arborescent from its accompanying the course of the blood- 
vessels — the coarser, and less regular granular appearance exhibited in 
parts of the liver and kidneys, especially at their most depending portions, 
the granules commonly adhering to the capsule of the viscus, when it is 
torn off — the partial consolidations of the lungs, particularly near their 
apex — the opaque patches in the lining membrane of the heart and arte- 
ries — are all specimens of the result of cacoplastic deposits which age 
or disease has produced ; and the more the nutrient function has been 
degraded in the individual, the more abundant will be the specimens of 
this cacoplastic deposit. But generally this deposit takes place more 

* The term cirrhosis (from the obsolete Greek word nip/a?, yellow), was first applied by 
Laennec to the contractile disease of the Jiver; because the interstitial deposit which causes 
the contraction is often yellow from being stained with bile. The term is obviously inap- 
plicable to contractile deposits in the lung and other parts; to which, nevertheless, the name 
has been applied. The epithets granular or contractile deposit are respectively more 
suitable to the forms in which this cacoplastic product manifests itself. 



DEPOSITS, CACOPLASTIC — GRAY TUBERCLE. 



299 



abundantly in one particular organ, in consequence of disease predis- 
posing it to suffer (§§ 31, 2). Thus, if a person, from habits of intem- 
perance, or other cause, has injured the function or structure of the liver 
or kidneys, in the lapse of time, as the nutritive function begins to fail 
from age and debility, the injured organ is the first to suffer, and be- 
comes the subject of cirrhosis, or granular degeneration; and this may 
destroy life by arresting circulation and excretion, &c. (§§ 170, 311), 
before other organs are much affected: hence dropsy, jaundice, albumi- 
nuria, &c. 

555. But there is another more general form of cacoplastic deposit, 
which takes place, when textural nutrition is degraded still further than 
in the preceding examples ; this is in semi-transparent, miliary, gray, 
and tough yellow forms of tubercle. Instead of (with Laennec) classing 
tubercle under the vague term of "accidental productions," or (with 
Carswell) as a "secretion sui generis" I have for many years referred 
tubercle to a degraded condition of the nutritive material, from which 
old textures are renewed, and new ones formed; and have held that it 
differs from fibrin or coagulable lymph, not in kind, but in degree, of 
vitality and capacity of organization.* These views have received 
almost demonstrative confirmation in the microscopic researches of Mr. 
Gulliver and others, which have detected in tubercle the materials of 
lymph, but in a degenerated and confused state, the cells being few, 
irregular, shriveled, with imperfect nuclei, and incapable of further de- 
velopment; no fibres being perceptible, and the main substance being 
composed of granular or amorphous matter. f [The microscopical ex- 

* A somewhat similar opinion, but less definitely expressed, has been entertained by Dr. 
Alison, and formerly by M. Andral; but these pathologists seem originally to have regarded 
tubercle chiefly as the product of a modified inflammation. 

t '-Corpuscles more or less globular or oval are seen in tubercles; but the granular 
matter preponderates as the tubercular mass increases. Cells may be recognized in the 
miliary tubercles; but, as they increase in size, the well marked and complete cells disap- 
pear. Tubercles appear to differ essentially from the plastic exudations, inasmuch as 
the cells of the latter not only grow into a higher organization, but increase in number 
towards the centre; in other words, plastic matter has an inherent power of multiplying and 
evolving organic germs. But tubercle has no such power: for it would appear that its pri- 
mitive cells can only retrograde and degenerate." {Gulliver's Appendix to Gerber's Anatomy, 
p. 87.) — " If a tubercle, or even the tissue of the lung near it, be slightly compressed be- 
tween two slips of glass with a drop of water, it will crumble down and break to pieces, 
the fluid being at the same time quite white or milky. This white appearance is attributa- 
ble to a great number of minute objects, the assemblage of which constitutes the substance 
of the tubercle. They consist for the most part of molecules, granules, and granulated cor- 
puscles, of various sizes, of aggregated granules without any tunic, and of collapsed tunics 
without any granules. These objects are mingled with a great many shapeless flakes and 
filaments, which are no doubt fragments of the membrane of the air-cells, and of the minute 
blood-vessels, which, when involved in a tubercle, become so extremely brittle, that they 
must necessarily form a considerable proportion of the objects occupying the field of the 
microscope. The granulated corpuscles of a tubercle are sometimes very large, C^g- or to off 
of an inch;) and the molecules and granules, which are very conspicuous, may frequently 
be seen on the point of escaping from them. . . . The semi transparent forms of tu- 
bercle and tubercular infiltrations owe their peculiarity to a great relative amount of granu- 
lated vesicles {cells, Gulliver) ; whereas the opaque white forms of tubercle are attributable 
to great numbers of isolated granules." — Mr. Addison's '■'Experimental and Practical Re- 
searches, fyc," Trans. Provincial Med. and Surg. Association, 1843, pp. 287-8. 

These quotations supply microscopic evidence in favor of views regarding the nature of 
tubercle, which I have long held and taught, and to which I was led by an attentive exami- 
nation of the common characters and changes of lymph, pus, and tubercle. A brief notice 
of these views may be found in the four editions of my little work on the " Pathology and 



300 



STRUCTURAL DISEASES. 



animation of tubercle presents the following characters: — 1. An amor- 
phous, transparent stroma, resembling, in chemical reaction, coagulated 
fibrin. 2. Minute unorganized granules, varying in diameter from the 
800th to the 1200th part of an inch, which are not unlike the albuminous 
granules of the blood. They do not invariably exhibit the same reac- 
tion with chemical agents, which would appear to be owing to the 
period at which they were deposited. 3. Cytobiasts, or imperfectly 
formed cells, varying in size between the 200th and 500th of a line. 
According to Lebert,* Drs. Hughes Bennett, and Leeper,f they never 
contain nuclei ; whilst according to Gulliver and Vogel, they are often 
nucleated. Dr. P. Blakiston says that " it is certain that a faint ap- 
pearance of a cell-wall may sometimes be seen around these corpuscles ; 
at other times, there are traces of such cells without any nuclei."! In 
recent firm tubercle, the amorphous stroma and cytobiasts predominate, 
the latter being in clusters. In soft tubercles, they are generally further 
apart, and less numerous, whilst the granules are greatly increased.— C] 
Every gradation may be found between euplastic and aplastic deposits; 
the cells and fibres, which are the representatives of organization, dimin- 
ishing in number and completeness, and the material becoming more 
granular, amorphous, or abounding in fat globules, in proportion as the 
deposit is degraded, until, in opaque, crude, or yellow tubercle, it is 
altogether aplastic, consisting of a mere aggregation of granules and fat 
globules, with mere traces of the remains of cells. 

I consider that the more solid forms of tubercle are entitled to a place 
among cacoplastic deposits ; because, although destitute of vascularity, 
they seem to possess a kind of structure like that of the lower kinds of 
fibro-cartilage and granular deposit. Their affinity with granular dege- 
neration (§ 544) is shown by their commonly occurring in the same 
subjects, and by their frequently exhibiting the same tendency to con- 
traction. In a very large majority of cases of chronic granular disease 
of the kidneys or liver, there are found more or less traces of tubercle in 
the lungs, its chief seat: and in a very few instances of chronic phthisis 
have I failed to find some degree of granular disease in the liver or 
kidneys. In acute phthisis and acute granular disease, local causes 
accelerate the degenerative change to a destructive extent in one organ, 
before there is time for others to become affected. 

556. Let us now trace the history of cacoplastic deposits in a few 
examples. The dense false membranes on the surface of serous mem- 
branes, may be often seen surrounded by a radiated wrinkling or pucker- 
ing of the adjoining parts, indicating that the new deposit has shrunk in 
size. A similar contraction is noticed in the deposits on and under the 
lining membrane of the heart and its valves, and causes a serious dis- 
turbance of their mechanism. The contraction of the chest, in some 

Diagnosis of Diseases of the Chest;"' in my " Lectures on Diseases of the Chest,' 1 published 
in the " Medu-al Gazette," of 1837-8; and in the l> Library of Practical Medicine," vol. [ii. 
1842; and u Williams and Clymer on Diseases of the Respiratory Organs," p. 337, Phiia., 
1844.] All these works were published long before any of the above microscopical exami- 
nations were made. 

* Physiologie Pathologique, &c , Paris, 1845. 

f Report on Tubercle, Dublin Quarterly Journal of Medical Science, No. VII. 

X Practical Observations on Certain Diseases of the Chest, &c. Phil, reprinted 1848. 



DEPOSITS, CACOPLASTIC — GRANULAR TUBERCLE. 



301 



cases of pleurisy, is, in part, dependent on the same property of caco- 
plastic deposits. This general tendency of false membranes to contract 
was long since pointed out by Dr. Hodgkin and Laennec ; and the fact 
has been subsequently applied by Dr. Cars well to explain the contraction 
of the liver in cirrhosis, which he considers to depend on a deposit in the 
intravascular filamentous texture prolonged from the capsule of Glisson. 
I do not consider that the contractile deposit in cirrhosis is exclusively 
confined to any texture, but is exuded from the distended blood-vessels 
themselves. False membranes, which exhibit the same contractile pro- 
perty, are sometimes found on the free surface of serous membranes, and 
especially along the course of the vessels (veins as well as arteries) ; and 
on the liver and lung, depressions from atrophy of the substance of the 
organ are sometimes seen under these deposits. There can be little 
doubt that these deposits are a fibrinous material exuded from trie vessels 
in certain pathological states, (congestion, chronic inflammation, and 
mal-nutrition,) and form a dense structure of low vitality, which, by its 
subsequent contraction, tends to constrict and compress the subjacent 
parts, and more or less to interfere with the passage of blood through 
them, and consequently with their secretion and nutrition. The same 
tendency is shown in the higher (less aplastic) forms of tuberculous dis- 
ease. Miliary or granular tubercles in the lungs, w T hen in considerable 
numbers, and not soon softening, cause a contraction of the lung, chiefly 
at the upper part, and a corresponding collapse in the upper part of the 
chest. I have met with many cases, in which a sinking in of the infra- 
clavian region took place before any symptoms of softening or excava- 
tion had occurred ; indeed, it is a very common sign of tubercles which 
long remain stationary. The still greater amount of collapse, in the 
advanced stages of tuberculous lesions, although partly dependent on 
other causes, is also in some degree connected with the contraction of 
cacoplastic deposits in the lungs and pleura. In the peritoneum, agglu- 
tinated tubercles often cause considerable contraction; and I have seen 
the omentum thus puckered up into a knotty mass. 

The microscopic examination of cacoplastic deposits at different pe- 
riods gives much explanation of these contractile changes. When recent, 
it consists of fibres with a great amount of granular matter, with and 
without cells, and more or less amorphous material. When examined 
older, and after having contracted, it is much more tough, and is found 
to be more distinctly fibrous, much of granular and amorphous matter 
having disappeared. Old contractile adhesions and cicatrices are still 
more dense, and are found to consist almost entirely of closely interwoven 
fibres, differing from those of fibro-cartilaginous tissues only in being less 
regular and distinct. It appears, therefore, that it is by the partial 
absorption of the granular and amorphous portion of the deposit, and by 
the closer approximation of the fibres or more organized constituent, 
that the condensation takes place. Hence it is that the structure so 
contracted is less liable to the further degeneration to which cacoplastic 
deposits commonly tend. Certain it is that, of different portions of caco- 
plastic deposit in the lungs and elsewhere, those that are contracted 
remain unchanged, whilst others pass into the aplastic state of opaque 
and softened tubercle. This contractile process seems, therefore, to 



302 



STRUCTURAL DISEASES. 



raise the deposit to a higher standard, in which, although below them, it 
is tolerated by the adjoining textures. But this very change may seri- 
ously injure the textures of organs, by contracting and compressing 
their vessels, and interfering with their nutrition and other functions ; 
and in this respect it may be classed with the highest, or most animal- 
ized variety of degeneration, the fibrous, which has already been de- 
scribed (§ 543). This is the chief mode in which the contractile diseases 
of the liver and kidneys gradually infringe on the circulation and secre- 
tion of these organs, and thus may eventually prove fatal (§§ 249, 375). 
The contraction which takes place near the summits and roots of the 
lungs, in the more limited, and therefore chronic forms of pulmonary 
tuberculous disease, often lays the foundation of emphysema of the lungs 
and habitual asthma. I have notes of a large number of cases illustra- 
tive of tlfis fact ; but such details belong to special pathology, and are 
reserved for another work. Similar contraction occurring in the deposit 
under mucous membranes of the alimentary and urinary passages, con- 
stitute strictures, which occasion much distress and serious disorder. 

557. Having adverted to the less degraded or degenerating form of 
cacoplastic deposits, we have now to notice those of a lower character, 
which tend to become aplastic. These include the commoner forms of 
tubercle. In the granular, miliary, gray, or drab-colored tubercles of 
serous membranes and parenchymata, we find a dense homogeneous 
solid, closely resembling some of the other cacoplastic deposits which 
have just been described. Their resemblance, and even identity, may 
often be well traced in chronic or subacute arachnitis, peritonitis, and 
pleuritis, in which portions of the affected membrane are covered with 
diffused patches of semi-opaque deposit, which no one would hesitate to 
call false membrane ; whilst in other parts, the same deposit occurring 
in separate granules, exhibits all the characters of granular or miliary 
tubercle. But how comes it (it may be asked) to assume the granular 
form ? In answer to this question, I may refer to the observations made 
on the products of inflammation (§ 449), where it was pointed out, that 
the effusion of lymph on an inflamed membrane is at first granular, and 
would continue to be so, if it were not drawn or spread into threads or 
films by the friction or pressure of the surfaces where it is poured out ; 
and several examples were cited, in which, from the absence of such 
friction or pressure, the granular appearance is preserved even in acute 
inflammation. In scrofulous and chronic inflammation, in which the 
matter effused is from the first less ductile and more consistent, the 
granular condition more generally prevails and remains even in spite 
of pressure and friction; and it is generally admitted, that the product 
of chronic inflammation of the peritoneum and arachnoid is always more 
or less granular. Even in acute inflammation of tuberculous subjects, 
recent lymph is commonly studded with opaque granules, which subse- 
quently would assume the character of tubercles. 

But tubercles do not always result from inflammation. In many 
cases, they are found disseminated in so many textures, after few or no 
symptoms of inflammation, that it is impossible to regard them otherwise 
than as the result of modified textural nutrition. The cell-germs by 
which the material of textures is renewed, are imperfect at particular 



DEPOSITS, CACOPLASTIC — TUBERCLE AND ITS CHANGES. 



303 



points; agranular or amorphous matter is deposited from the plasma, 
and concretes without fibres or regular cells being developed; at this 
point, a granulation appears, and gradually hardens. Where a granule 
has once been formed, it becomes a nucleus for the concretion of more: 
a new habit or mode of nourishment is established at the spot; or, to 
speak less figuratively, cacoplastic matter (if present in the blood plasma) 
concretes around it by a process similar to that by which fat attracts fat, 
or bone, osseous matter ; perhaps the process is not wholly unlike that 
of crystalization. But however it happens, the result is, that the granular 
tubercle grows, and may attain the size of a millet-seed, hemp seed, or 
even a small cherry-stone ; or, being subjected to pressure, may slightly 
spread or flatten into various shapes. 

The microscopic character of these miliary or granular tubercles is 
the complete predominance of minute and often irregular granules, and 
the comparative absence of fibres and cells, of which mere traces are 
seen, at least in the older specimens. The granules are aggregated 
together by an amorphous material, the solidity of which gives hardness 
and some translucency to the mass, for acetic acid or alkalies, which 
dissolve this cement, loosen the granules and render them distinct. The 
chemical nature of granular tubercle is albuminous, with some gelatine 
and a little fat, the latter in very minute proportion, and occupying the 
centre of some granules; and the gelatine being probably the amorphous 
cement just noticed. In all these characters, we find a close analogy 
to the granular degeneration of textures (§ 544), and of which doubtless 
these deposits are a kind of exaggeration. 

558. Tubercles rarely grow much or last long without exhibiting 
another change in their appearance. They lose their semi-transparency, 
and become of an opaque or dead pale yellow hue, like the color of raw 
potato or parsnip. This is the transformation to crude yellow tubercle 
first described by Laennec. This change is the result of a further de- 
gradation or degeneration of the deposit. The few fibres and cells which 
are to be detected in gray tubercle become indistinct, the interstitial hya- 
line or amorphous solid diminishes, and oil globules appear in its stead, 
and the mass becomes less coherent and more granular, and therefore 
quite aplastic. Generally the change begins in the centre of the mass; 
apparently because, being devoid of vessels, the centre is further removed 
from the vivifying influence of the blood. In a similar manner, the 
cornea and other non-vascular textures become opaque from deficient 
supply of sustaining nutriment in the plasma, and may wholly lose their 
organization (§ 269). A parallel degradation is observed in the dege- 
neration of fibrous and cellular tissues into granular matter, recently 
pointed out as the result of mal-nutrition (§ 544). But not only will 
deficient supply of plasma promote the transformation of tubercle from 
gray to opaque; but an undue flow or accumulation of blood, as by con- 
gestion or inflammation in the neighborhood, will also accelerate this 
change, just as they hasten the disintegration of lymph and of compressed 
textures, the plastic into the aplastic, by the increased warmth and afflux 
of fluids exalting chemical affinities in a material which has no vital 
power of resistance by which living tissues maintain their integrity. 

559. But tubercle is frequently deposited at first in this yellow, opaque 



304 



STRUCTURAL DISEASES. 



state, this circumstance being a mark of the still more degraded condition 
of the nutritive function; and the more extensive forms of tuberculous 
disease commonly abound in this aplastic matter. Thus in rapid phthisis, 
whether resulting from acute inflammation in a scrofulous subject, or 
from the excessive prevalence of a scrofulous diathesis (cacoplastic matter 
in the blood), yellow tubercle commonly forms a large portion of the 
deposit; and it is in these cases that its resemblance to, and connection 
with, coagulable lymph, may be best seen.* Yellow tubercle is rarely 
so hard or so tough as the gray or semi-transparent kind ; and in the 
cases of rapid deposit just mentioned, it is often much softer and more 
friable. Now, this is the commencement of a change to which the lowest 
forms of tubercle tend — that of maturation and softening into a cheesy 
substance. The conversion of the gray into opaque tubercle, and the 
further softening of this, seem to be the converse of the contractile pro- 
cess to which the higher class of cacoplastic deposits tend: in that (the 
contractile process) the deposit becomes more dense and organized: in 
this (opaque change and softening), the deposit becomes less dense, and 
loses the little trace of structure which it possessed; it degenerates into 
an amorphous, granular mass; and being lifeless it is no longer nourished ; 
but its granules lose their cohesion, and become disintegrated by the 
chemical action of the adjoining fluids. f Mr. Gulliver and others have 
observed a remarkable increase of fat globules in softened tubercle. In 
fact, from the time that tubercle assumes the opaque form, these oil 
globules appear to increase; until it is either softened and eliminated, or 
undergoes the petrifactive change to be described hereafter. 

The formation of fatty particles in old pus (§ 460), in atheroma of 
arteries, and in chronic inflammatory deposits and gangrene of the 
lungs, seems to show that fat is sometimes a debris of animal matter, 
as in the conversion of flesh into adipocire (§ 543). The lenticular cor- 
puscles concentrically striated, supposed by Gruby to be characteristic 
of softened tubercle, Mr. Gulliver has found, in various textures, uncon- 
nected with tubercle or any other disease. The detection, by Dr. Davy, 
of oleine and margarine in opaque exudation corpuscles in the lungs 
(§ 543), and the observation, by myself and others, of numerous fat 
globules in deposits in the kidneys, spleen, and vegetations on the valves 
of the heart — show a tendency to the production of fat in all degenerated 
plasmata. In many instances, the fatty matter appears in a solid form, 
either crystalized, or in granules, rather than as distinct oil-globules ; 

* The affinity between lymph and tubercle was recognized by older writers ; and after 
it bad been kept out of view by tbe too exclusive opinions of Bayle and Laennec, it was 
again pointed out by Dr. Alison. (Trans, of Medico-Chirurg. Soc. of Edin., vols. i. and iii.) 

*f" Dr. Elliotson, I think, first suggested that the softening of tubercles is due to a sponta- 
neous chemical change. I also consider the change to be chemical ; but to be much promoted 
by the action of fluids from adjoining parts. So long as tubercles are kept free from super- 
fluous moisture, they manifest little disposition to change; but an afflux of fluids around 
them hastens their maturation and softening. This effect may be rudely illustrated by the 
action of water or serum on coagulated albumen. When nearly dry, it is tough and semi- 
transparent ; but when well moistened, it becomes opaque, soft and friable. The softening 
and disintegration of clots of fibrin by warmth and moisture give another illustration of the 
same change. [Lebert believes that the softening of tubercle depends upon the liquefaction 
of the transparent hyaline mass, in which the granular matter is imbedded. — Physiologie 
Pathologique, §r., Paris, 1845. — C] 



DEPOSITS, APLASTIC — TUBERCLE AND ITS CHANGES. 



305 



and this fact suggests that a change in kind, as well as an excess in 
quantity, of fat in the deposits, has occurred, and probably prevents its 
absorption. These facts, which have before been noticed under the 
head of fatty degeneration (§ 545), prove that morbid deposits are ame- 
nable to the law of the fatty or hydrocarbonaceous transformation, in 
common with natural structures ; and they are more liable to this sinking 
in the scale of organic matters, in consequence of their low vitality; 
and from their extravascular position placing them beyond the reach of 
the decarbonizing influence of the circulating blood. As the change 
seems to be in a great measure spontaneous, and promoted by moderate 
moisture, it increases with the age of the tubercle, within certain limits, 
beyond which the mineral transformation, petrifaction (also chemical) 
ensues. But the softening, if early, depends on a decomposition which 
is more destructive, and this, by generating matter offensive to the ad- 
joining textures, and to the whole frame, may cause local and constitu- 
tional irritation, so strongly marked during the extensive and rapid soft- 
ening of tuberculous deposits.* 

560. But in these different changes in tuberculous matter, as well as 
in the original deposition of this matter, the adjacent living parts have a 
considerable share. A miliary tubercle, from its first formation, may 
become a cause of irritation and obstruction to the contiguous textures. 
The amount of this irritation and obstruction will depend on the natural 
or present vascularity and excitability of the part, its function, and the 
situation and size of the tuberculous deposit. Thus, in vascular textures, 
especially parenchymata, there is more tendency to mischief and change 
than in serous membranes. Where the irritation is very slight, it may 
merely cause so much determination of blood as to promote the growth 
of the gray tubercle. Where it is more, it may cause the conversion of 
gray into yellow tubercle, its further increase in this form, and its soft- 

* [Rokitansky thus describes the softening of tubercle. " After the suppuration has existed 
for some time in the state of crudity, it becomes, as it were, loosened in its textures, and 
usually increases in volume; it breaks up on slight pressure, and becomes more moist; then 
changes into a yellowish, dissolving, casein-like, fatty and viscid matter, and finally breaks 
up into a thin, whey-like, acid fluid, in which flocks and shreds — the remains of the imper- 
fectly disintegrated tubercle — are observed swimming. This is tubercular pus. . . . 

" The softening consists in the solution and disintegration of the solid ground-work of the 
tubercle, into a fluid containing an abundance of the minutest molecules. This change is 
followed by a separation and isolation of the above-named histological elements of tubercle, 
which undergo more or less marked alterations by their immersion in the fluid; the cells 
become distended, corroded, and are finally dissolved; the nuclei shrivel, and assume irre- 
gular forms, becoming angular and indented. Finally, in softened tubercle we meet with 
free fat. 

" The dissolved tubercle consists — 
" a. Of a fluid with minute molecules. 

" b. Of altered nuclei and cells isolated in the manner we have described. 

" c. Of free fat in the form of elementary granules, and distinct globules of a larger size. 

" 2 The other metamorphosis of this form of tubercle is cretefaction. It occurs as a se- 
condary change, never attacking tubercle in its original form, but confining itself to the 
dissolving or dissolved tubercular blastema. 

" In softening or softened tubercle, the calcareous salts and fat occur in the form of free, 
distinct, or aggregated elementary molecules, or in granular cells ; the fat also not unfre- 
quently occurs in the form of large drops or of crystals of cholesterin. In this process, the 
softened tubercular mass gradually thickens into a moist, fatty, viscid kind of plaster, and, 
finally, diminishing in volume, is converted into a mortar like concretion." — (Handbuch der 
pathologischen Anatomie, p. 398, from British and Foreign Medico-Chirurgical Review, vol. i., p. 
173.)— C] 

20 



306 



STRUCTURAL DISEASES. 



ening. If the irritation be still greater, inflammation is excited around 
the tubercle ; and its marks are often seen after death in the areola of 
vascular redness; and the products of this inflammation (pus, lymph, 
mucus, serum, &c.) may also hasten the softening of the tubercle, their 
mixture together, and their evacuation by ulceration into adjoining open 
surfaces. Or, the product of inflammation being more solid and plastic, 
consolidations, or false membranes, are formed around the tubercle, and 
its irritating influence may be thus circumscribed. Thus, although we 
have just mentioned that the opacity, maturation and softening of tuber- 
cle, depend essentially on a further degeneration and loss of structure, yet 
these changes are much promoted by the afflux of blood to the neighbor- 
ing parts. 

561. In the absence of any of the circumstances just mentioned, which 
tend to promote the increase or further change of tubercle, we find that 
it may remain harmless for months, and even for years; but then it often 
exhibits further transformations which may be considered spontaneous 
or chemical. This remark does not apply to the change of the less ca- 
coplastic deposits by contraction, which has been already noticed as an 
elevation of the deposit to the condition of a fibrous tissue nourished and 
preserved as a living part. In the lungs, the consolidations may remain 
long without any contraction, but they become deeply blackened by an 
accumulation of the peculiar black matter of the lung. Yellow and 
softened tubercle, if not evacuated, in time becomes replaced by a plas- 
tery, or putty-like matter, composed chiefly of phosphate of lime, and 
often containing solid concretions, consisting entirely of that earthy mat- 
ter. — [These cretaceous or puttaceous remains, are generally found en- 
cysted. — C] This petrifactive change reminds us of what takes place in 
the cacoplastic deposits in the coats of arteries and on serous membranes 
(§§ 544, 553), constituting what is erroneously called ossification; and 
this completes the fourth and last parallel with the degenerations which 
kindred textures undergo from the influence of age or disease ; the os- 
seous or mineral transformation. The calcareous conversion of tubercle 
can be explained only on the supposition that the organic matter is ab- 
sorbed, and the earthy salt is deposited in its place. This is exactly 
like what takes place in true petrifaction of organized bodies, the silica 
or calcareous substance being substituted molecule for molecule: so 
that, when all is converted into stone, the shape of the organized body is 
retained. And we further learn from this that the animal matter of 
tubercles may be absorbed. The occasional absorption of tuberculous 
matter is further proved by its accumulation in the bronchial and me- 
senteric glands, which sometimes contain it when the lungs and the 
intestines present little more than traces of it, such as cicatrices, with 
some cretaceous matter in them. In the bronchial glands, too, the 
tubercle very commonly exhibits the petrifactive change, and the concre- 
tions so commonly found in these glands may generally be ascribed to 
this cause. 

562. The circumstances which degrade the material of nutrition, and 
lead to the deposition of cacoplastic and aplastic matter, may be either 
local or general. Of the local causes, congestion and the lowest and 
more chronic forms of inflammation have been mentioned as capable of 



DEPOSITS, CACOPLASTIC AND APLASTIC TUBERCLE. 307 



determining cacoplastic deposits; but even in these cases it is probable, 
that the general cause also more or less operates — that is, a degraded 
state of the plasma of the blood. Congestions and chronic inflamma- 
tions certainly cause cacoplastic effusions ; but then, such congestions 
and chronic inflammations do not easily occur in healthy subjects; and 
the want of health may imply that the plasma of the blood is bad in 
addition to the local cause. But practically, it is of great importance 
to keep in view the local as well as the general cause, for the former is 
often more tractable than the other, and it is by guarding against it that 
slighter degrees of the general cause (diseased plasma) may be pre- 
vented from doing mischief. But the general cause, when present in 
great degree, leads to cacoplastic and aplastic deposits, as modifications 
of ordinary textural nutrition, independently of inflammation or even 
congestion. This general cause thus prevailing, constitutes the chief 
element of the scrofulous diathesis or tuberculous cachexia, and we have 
before mentioned that a defect of the red particles and an excess of fibrin 
in the blood constitute its most remarkable feature (§§ 185, 211). In 
this condition of the blood there is an increased disposition to deposit, 
and often an abundance of the fibrinous or nutritive material, but an 
imperfect vitality or organizability of this material, so that when depo- 
sited instead of being assimilated to the textures, it forms the degene- 
rated structures or mere granular or amorphous deposits, which we have 
been describing. But with this condition of the blood, these deposits 
must be greatly promoted by all varieties of hypersemia, and prevail most 
in organs which receive the largest amount of blood. Hence, the pecu- 
liarly pernicious effect of inflammation of internal organs, especially the 
lungs, in scrofulous subjects. Even acute inflammation maybe unequal 
to raise the nutritive material to a plastic standard at which it may be 
organized or absorbed, or to mature it to the process of complete suppu- 
ration by which it may be speedily excreted : but the matter thrown out 
is cacoplastic or curdy lymph, remarkable for its opacity and want of 
cohesion, or a caseous kind of pus, inorganizable, inert, irremovable by 
absorption, and permanently obstructing or compressig the structures in 
which it accumulates, until it gradually excites an irregular destructive 
suppuration or ulceration, forming vomica, or imperfect abscesses per- 
vading the structures, and without walls capable of healing, whilst under 
the depressing and irritating influence of the morbid matter decaying and 
becoming decomposed, the body wastes with hectic fever, night-sweats, 
and colliquative diarrhoea. So likewise fevers, by causing congestions in 
organs, lead to the production of a crop of these deposits, from which 
tuberculous disease takes its origin.* 

* [No point of pathology has been the subject of more violent disputation than the ques- 
tion, whether or not, tubercle is the result of an inflammatory action. Laennec opposed the 
inflammatory theory. Carswell has advocated warmly and ingeniously the same view. Dr. 
Baron of Gloucester, thought that tubercles were not the product of any species of inflam- 
mation. Broussais was the ardent advocate of the inflammatory origin of tubercle. Andral 
thinks, that where predisposition exists, that any slight local congestion of blood will give 
occasion to its production. Dr. Alison of Edinburgh, is probably the most elaborate supporter 
of this doctrine, from his own observations, and from the experiments of others. Hughes Ben- 
nett, Evans, Blakiston, and others, maintain the positive side at the present time ; whilst Nicol- 
lucci, Lebert. Gellerstedt and Rainey, oppose it. The true state of the question is, to our 
mind, so justly stated by Dr. Leeper, that we give it in his own words. " For ourselves,'' he 



308 



STRUCTURAL DISEASES. 



563. The lungs and bronchial glands are by far the most common 
seat of tubercles; when found elsewhere, tubercles commonly abound 
more, and are more advanced in these parts. The situation of the pre- 
valence of tuberculous disease varies also with the age of the subject. 
Thus, M. Papavoine found yellow tubercle in children to occur especially 
in the cervical and mesenteric glands ; next, in the spleen, pleura, liver, 
and small intestines; less frequently, in the large intestines and perito- 
neum; and more rarely in other parts. In 350 consumptive (chiefly 
adult) cases examined by M. Louis, tubercles were found in the small 
intestines in one-third of the whole ; in the mesenteric glands, in one- 
fourth; in the large intestines, in a ninth; in the cervical glands, in a 
tenth; in the lumbar glands, in a twelfth; in the spleen, in a fourteenth 
of all the cases; and in other parts, in smaller proportions. [In 100 
young subjects, Lombard found the bronchial glands affected in 87; the 
lungs in 73; the mesenteric glands in 31; and the spleen in 25. In 
100 adults, the lungs not included, he found the intestines affected in 
26; the mesenteric glands in 19; the bronchial glands in 9; and the 
spleen in 6. The relative frequency of tuberculization of the bronchial 
glands in the child and adult, is as 87 to 9, or 9§ times more frequent 
in the former. Of three hundred and twelve tuberculous children, Rilliet 
and Barthez found the lungs free from tubercles in one-sixth only. Ac- 
cording to MM. Rilliet and Barthez, we find tubercular matter in children 
more frequently in the lung than in any other organ; next the bronchial 
glands; afterwards, but at some distance, the mesenteric glands and 
small intestines. After these organs, the pleura and spleen are most lia- 
ble ; and then the peritoneum, the liver, the large intestine, the meninges, 
the kidneys, the heart, stomach and pericardium. The same order 
exists with regard to the amount of tuberculization; those organs in 
which most frequently we find tuberculous matter, are those, in general, 
in which it occurs most abundantly.* — C] 

The greater liability of the lungs to tuberculous deposits, has been 
lately ascribed by Dr. Campbell and others to the finer size of their 
capillary vessels, which causes them to act as filters to the blood, arrest- 
ing the tuberculous matter, which is supposed to become solid in the 
blood itself. But this view is untenable for several reasons. 1. If the 
fine size of capillaries were the chief cause of the deposit, it should take 
place abundantly in muscle, the capillaries of which are even finer than 
those of the lungs. 2. If the cause of the first deposit were a solid 
matter obstructiug a vessel, the appearance of vascular distention and 
obstruction would be obvious in the earliest formation of tubercles, and 

observes, "we have long thought that authors have been hunting after a shadow, in endea- 
voring to settle the point in question. Believing as we do. that tubercular matter exists in 
the blood of the scrofulous, in the form of a tubercular plasma, we are of opinion, that it may- 
be exuded in that condition of the capillaries, in which, under other circumstances, fibrin 
would be effused. If the latter state be called inflammation, and it is only an excited state 
cf nutrition, — then in the case of tubercular effusion, the inflammation is a peculiar and 
anormal one, and the product is also anormal" (a). Dr. H. Bennett holds nearly the same 
language. — C] 

* Williams and Clymer on Diseases of the Respiratory Organs, p. 333. 



(a) Report on the Pathology of Tubercle. — Dublin Quarterly Journal of Medical Science. 
No, YL 



DEPOSITS — TUBERCLE — CAUSES. 



309 



the deposit would exhibit somewhat of a capilliform shape, which is not 
the case. 3. The deposit has been distinctly traced by Messrs. Gulliver 
and i\.ddison to be extravascular, sometimes on the surface of the air- 
cells, and sometimes in or under the membrane composing them. I 
think it highly probable that tuberculous matter may form within the 
blood-vessels themselves; and I have repeatedly found something pre- 
senting all the external characters of yellow tubercle in the blood-vessels 
of tuberculous lungs. In fact, wherever fibrin may coagulate, there its 
degraded form, tubercle, may occur; and I cannot but refer to the case 
of opaque softening of clots of fibrin in coagula in the heart and great 
blood-vessels as bearing on this point. Formerly, this softened fibrin 
was mistaken for pus: Mr. Gulliver pointed out this error by showing 
that it had no pus globules. But its aspect and microscopic composition 
differ in no essential particular from those of soft tubercle, and the views 
which I have given would identify them in nature. This leads me to 
infer that the fibrin of blood stagnant within vessels, or extravasated 
from them, in tuberculous subjects, may sometimes change into aplastic 
tubercle. But the reasons before stated make it obvious that the early 
forms of tubercle are extravascular deposits, resulting from modifications 
of the ordinary nutritive secretion. 

I believe that several circumstances contribute to render the lungs 
especially liable to tuberculous deposit. 1. Their great vascularity and 
the large quantity of blood that passes through them, which makes them 
largely partake of any disorder in the condition of this fluid. 2. Their 
being a chief seat of the formation of fibrin, that principle being more 
abundant in arterial than in venous blood (§ 194). 3. The softness and 
yielding nature of their texture, which permits effusion to take place 
more readily than denser textures do. 4. Their exposure to external 
causes of disease, whether by cold and irritations directly entering by 
the air-tubes, or by circumstances operating through the medium of the 
circulation. In hot climates, cacoplastic diseases affect the liver and 
other abdominal viscera more than the lungs; the same persons there 
suffering from chronic liver disease and dysentery, who, in a cold climate 
would fall victims to phthisis. 

564. As we have found (§ 562) that the cacoplastic condition of the 
blood of tuberculous or scrofulous subjects comprises a diminution of the 
red particles and a preponderance of fibrin, so we can state that the 
causes w T hich develop this condition, and therefore induce tuberculous 
disease, are such as intelligibly induce one or both of these changes. 
Insufficient food, want of pure dry air, of warmth, and of light, long- 
continued mental depression, aggravated and prolonged disease of the 
digestive organs, insufficient excretion (§ 249), and the injurious influ- 
ence of fevers and other serious diseases, are acknowledged causes of 
tuberculous disease, and may be considered to operate in both ways. 
Excessive evacuations of blood, or of the more animalized secretions, 
and severe courses of mercury, also predispose to phthisis, and perhaps 
act chiefly by reducing the red particles of the blood, and the quality of 
the plasma. The cessation of growth, the termination of pregnancy, 
the stoppage of habitual discharges, especially purulent, and the ampu- 
tation of a limb, all of which circumstances are known to favor the de- 



310 



STRUCTURAL DISEASES. 



velopment of tubercle, may be supposed to operate chiefly by increasing 
the proportion of fibrin in the blood, when there is not a sufficiency of 
red particles, and of vital power, which is represented by them (§ 183) 
to give to this fibrin a due amount of elaboration and capacity for the 
properties of life. 

565. The treatment of cacoplastic and aplastic deposits, and of the 
conditions which lead to them, involves avast number of details, accord- 
ing to their kind, situation, extent, and other circumstances in which 
they occur. It is not consistent with the limits of this work to enter into 
these details ; but it is hoped that a rational view of the principles on 
which these deposits are to be prevented and treated maybe deduced 
from the foregoing account. This view will comprehend those measures 
w T hich have the best sanction of experience. 

The elements of cacoplastic diseases chiefly to be kept in view in the 
treatment are: — 1, the disordered condition of the blood, and its causes ; 
2, the disordered distribution of the blood, and its causes; and 3, the 
presence of the deposit, and its effects and changes. The second element 
comprehends the varieties of local hyperemia, which we have found to 
be so much concerned in producing the higher kinds of cacoplastic de- 
posit (§ 553), and in promoting the formation and changes of those of a 
lower character (§ 560). Hence, the remedies against inflammation, 
determination of blood, and congestion, are frequently more or less 
needed in the prevention and treatment of cacoplastic and aplastic 
deposits. But, except as preventives, the utility of this class of reme- 
dies is generally limited to those of a topical kind, such as local blood- 
letting, counter-irritants, revulsives, derivants, and alteratives (§ 174). 
No remedies of this class have appeared to be so generally useful as 
counter-irritants of the milder class, rubefacients, extensively and regu- 
larly applied by friction over a large surface of the body. These operate 
not only as revulsives, which diminish the congestions and irritations of 
internal organs; but also by increasing a free circulation on the surface, 
w T hich promotes the purification of the blood by perspiratory excretion, 
and aids the lungs in the process of arterialization. 

566. The more constant and important element to be considered, in 
the treatment of cacoplastic and aplastic diseases, is the first named — 
the diseased condition of the blood ; and this more demands attention, 
the more general and the more degraded are the deposits. The first 
point to be attempted is the removal or counteraction of the several 
causes before enumerated (§ 564), as contributing to induce the diseased 
condition of the blood. Thus a sufficient supply of food of a nutritive 
and digestible quality, comprising especially the highest order of pro- 
teinaceous articles (§ 60), — free access to a pure dry air and light, while 
the warmth of the body, particularly of the surface and extremities, is 
carefully secured by adequate clothing, and regular exercise proportioned 
to the strength — the removal or counteraction (so far as possible) of dis- 
eases impairing digestion and excretion, and of depressing mental or 
bodily influences, — are among the first objects to be aimed at in treating 
cacoplastic diseases. Where excessive losses of blood or other evacua- 
tions have contributed to lower the plastic process of nutrition, a generous 



DEPOSITS, CACOPLASTIC AND APLASTIC — TREATMENT. 



311 



animal diet, and tonics, especially those containing iron, are especially 
indicated. Where the altered condition of the blood can be traced to an 
excess of ill-developed fibrin accumulating after the cessation of growth, 
the termination of pregnancy, the amputation of a limb, or the sudden 
stoppage of an habitual purulent or other discharge — means to eliminate 
the superfluous matter from the blood, either by increasing the natural 
secretions, or by establishing an artificial drain by blisters, setons, issues, 
suppurating counter-irritants, &c, are distinctly indicated; whilst tonic 
and invigorating measures may be also useful to raise the plasticity of the 
blood to a higher standard. Some of the remedies to be mentioned in rela- 
tion to the third indication, are sometimes useful in promoting this object 
also, such as codliver oil, nitric acid, and combinations of iodine, w 7 hich 
have direct influence on the nutritive functions. 

The foregoing measures may be considered rather as preventive than 
curative ; but in so far as they may succeed in arresting the augmenta- 
tion of deposits already formed, and in improving the nutritive function 
in general, they will favor the limitation of the deposits, and their gra- 
dual absorption or quiescence in contraction (§ 556 J or calcareous trans- 
formation (-§ 561). 

567. The third object to be regarded in the treatment, is the deposit 
that is already formed, with the view to promote its removal or quies- 
cence. This end is the more difficult of attainment, and the class of 
diseases therefore more intractable, because, being for the most part 
non vascular, the deposits are little under the influence of absorption 
and of the vascular currents, by which it and other changes are effected. 
Unlike with the euplastic products of inflammation, and, in some instances, 
unlike with a simply overgrown texture or organ, the changes of absorp- 
tion are slow to reach deposits which are very solid and remote from 
vessels ; and it is doubtful whether any remedy that we can use can surely 
promote their removal, unless, perhaps, by the simultaneous destruction 
of the texture which contains the deposits. The constitutional influence 
of mercury, has seemed to me to hasten the softening and evacuation of 
pulmonary tubercles; but this is by such a work of destruction, and its 
influence on the blood has been already mentioned to be injurious. Drs. 
Graves and Stokes, and others, have, however, recommended mercury 
in the earliest stage of tuberculous disease. My own experience would 
lead me to avoid the specific influence of mercury, in all cases of mere 
tubercle ; but I have given it with advantage in cases of subacute and 
chronic inflammation simulating tuberculous disease, and even where 
tubercle probably existed in a limited extent. I am less doubtful of the 
utility of mercury (chiefly by way of inunction), in incipient cacoplastic 
or tuberculous deposits on serous membranes, particularly the peritoneum, 
which is a general result of chronic inflammation. I have successfully 
treated several cases, in which the signs and symptoms left me in no 
doubt as to the existence of tuberculous peritonitis, by ointment of iodide 
of mercury to the abdomen (covering the surface with India rubber cloth), 
together w 7 ith iodide of potassium internally. Whether mercury is of 
any use in granular disease of the liver and kidney, is a subject of doubt. 
Alkalies and their carbonates, and iodide of potassium, have better claims 
to notice, although their power to dissolve cacoplastic and aplastic de- 



312 



STRUCTURAL DISEASES. 



posits in the body is very uncertain. The occasional subsidence of exter- 
nal scrofulous tumors under their use is the best argument in their 
favor; and they have this advantage, that when judiciously administered, 
they do not injure the blood or the constitution. The}' act best, and are 
longer borne, when combined with some amylaceous or mucilaginous 
material, such as decoction of Iceland moss, or fluid extract of sarsapa- 
rilla, to which may be added a little tincture of hop, or some other nar- 
cotic ; and I have found this combination frequently useful in the early 
stages of tuberculous disease, where there is no fever, active inflamma- 
tion, or tendency to hemorrhage. Whether the iodine and alkali ever 
directly promote the solution or absorption of tuberculous matter, I am 
still in doubt ; but the signs of the presence of limited tubercles have, 
in many instances, diminished during their use, and the patients have 
regained color, flesh, and strength. Other combinations of iodine, par- 
ticularly with iron, have been recommended in scrofulous disease. The 
iodide of iron, and other preparations of this metal, I have found very 
beneficial in cases of ensemia or general weakness, without much fever 
or local inflammation ; but I have seen no reason to suppose that they 
promote the removal of tubercles already formed. 

568. But there are other agents which have been found of decided 
utility in cacoplastic and aplastic diseases, and we shall better under- 
stand their mode of operation if we again advert to the nature of the 
deposits and consider what means are likely to promote their removal, 
by causing their solution or disintegration. Cacoplastic deposits consist 
of albumen or protein, with a little (insoluble) gelatine, and minute mole- 
cules of fat contained in the granules. The more granular the deposit, 
and the lower in the scale of organization, the more do these fatty mole- 
cules abound; and in opaque tubercle and atheroma they are so much 
increased as to coalesce and form large oil globules, as well as some solid 
forms of fatty matter. The most effectual solvent of all these consti- 
tuents are caustic alkalies, especially liquor potassae, which dissolves the 
protein, and forms a liquid soap with the oil. But it is impossible to 
administer caustic alkalies in sufficient quantity to exert this solvent 
power through the blood, both because they would irritate the stomach 
and vessels in their passage, and they would soon meet with such an 
amount of acid, particularly carbonic acid, as to deprive them of the 
greater part of their solvent power. The same objection applies to the 
use of acetic acid, which has been recommended with a similar object. 

Other agents have been extolled which might be supposed to be useful 
by dissolving the fatty particles of tubercle, and thus promoting its dis- 
integration; of this class are naphtha or pyro-acetic spirit, oil of turpen- 
tine, tar, sulphuric ether, and various fixed oils. Naphtha, which has 
been so highly recommended by Dr. Hastings in the treatment of phthsis, 
has in my hands proved serviceable in a very limited number of cases, 
in which, by its effect in checking profuse purulent secretion, and the 
cough, hectic, and wasting accompanying it, it has appeared to me to 
operate like the balsams, gum resins, and turpentines, rather than by any 
specific influence on the tuberculous disease. So, like these, it often 
unduly checks expectoration, and excites pain and tightness of the chest, 
and hard cough, which have ended in inflammation or hemorrhage. 



DEPOSITS, CACOPLASTIC AND APLASTIC — TREATMENT. 313 



Its utility is further limited, like that of other medicines mentioned before, 
by its tendency to irritate or disorder the stomach. 

Fixed oils also possess a solvent power on the fat of tubercle, and they 
have no such irritating or active properties towards the textures as to 
deter us from using them in quantities much greater than can be given 
of any of the above-named agents, and sufficient to justify the inference 
that they do exercise a very marked influence on nutrition, and do there- 
fore thoroughly and abundantly pervade the textures of the body. But 
the greater number of fixed oils soon disagree with the stomach, bowels, 
or liver, causing nausea, inappetency, diarrhoea, bilious disorders, and 
other evil effects formerly noticed to result from excess of fat in food 
(§ 60), and this they appear to do in proportion to their proneness to 
absorb oxygen and become rancid, and therefore acrid, and often losing 
their fluidity. In these respects fish oils have greatly the superiority, 
being more permanently fluid and less liable to turn rancid, provided 
they be not contaminated with putrid matter in their manufacture (which 
is commonly the case, and they therefore require to be purified with ani- 
mal charcoal). Of fish oils, experience chiefly testifies in behalf of that 
from the liver of the cod ; but analogy favors the supposition that sperm- 
aceti oil, and seal oil, if equally purified, would be not less eligible, and 
they would have an obvious advantage in their more abundant supply, 
and lower price.* But it is important that the oil should be as free from 
taste and smell as possible, and for obvious reasons, I prefer that which 
by cooling and settling, or by filtration, is deprived of most of the stearin. 
Such an oil given in doses gradually increased to a table-spoonful three 
times a day, in the great majority of cases, agrees well with the stomach 
and bowels, increases rather than impairs the appetite, and, if continued 
for some weeks or even months, promotes in a marked degree the func- 
tion of nutrition, increasing the strength as well as the flesh, and giving 
increment to all the textures. Nor is this surprising when w T e consider 
that the nuclei or rudimental molecules of all structures appear to consist 
of fat (§ 523), which the oil in its highly divisible state, supplies and 
renews in the manner most conducive to active and healthy nutrition. 
Its peculiar fluidity and little proneness to change also enable it to per- 
vade all structures, and to penetrate even into imperfectly organized 
deposits, and by softening their concrete fatty molecules, and rendering 
more permeable and supple their w T hole mass, brings them more under 
the influence of the adjoining living parts, through the circulation in 
which, either their vitality and nutrition are improved and maintained, 
or, if incapable of improvement, they are gradually dissolved and 
absorbed away. 

Such appears to me the mode of operation of the cod-liver oil, assur- 
edly the most efficacious of all medicinal agents in the treatment of caco- 
plastic and aplastic deposits, and one which, after two years' constant 

* I think it scarcely necessary even to advert to a supposition formerly general and still 
entertained by a few, that cod-oil owes its efficiency either to its offensive impurities, or to 
any iodine which it contains. I will merely state that in some hundreds of cases in which 
I have prescribed the oil, the best effects have generally resulted from the use of the purest 
kind ; and in many of these cases various forms of iodine had been exhibited without pro 
ducing any of those marked changes which followed the taking the oil. 



314 



STRUCTURAL DISEASES. 



experience in its use, is still frequently surprising me by the wonders 
that it occasionally works even in aggravated and advanced cases of 
scrofula, mesenteric disease, pulmonary consumption, chronic pneumonia 
and pleurisy, and chronic rheumatism. 

But no remedy, however beneficial, should lead us to neglect attention 
to those general and hygienic measures by which the constitutional health 
is promoted and sustained ; or, in other words, the great functions of circu- 
lation, respiration, digestion, absorption, and excretion are promoted. Men- 
tion has so often been made of these measures, that it is needless to specify 
them again; and we may conclude this subject by adverting to means 
which may promote the absorption of cacoplastic and aplastic deposits. 

That such absorption does take place, is indisputably proved by the 
changes in chemical composition, as well as in physical condition, that 
these deposits undergo in process of time (§§ 556, 561).* The most 
salutary of these changes, and the absorption of the most injurious part 
of the deposits, are promoted by as free and active a circulation through 
and near the affected part as can be carried on without inducing irrita- 
tion or hyperaamia. Hence the utility of regular exercise, and of frequent 
friction of the surface in the vicinity of the seat of the deposits, some- 
times aided by rubefacient applications or salt water aspersions. The 
more active circulation thus excited promotes the gradual solution of 
the deposits, chiefly by the oxidating current of arterial blood that it 
directs through their neighborhood ; and the inquiry naturally suggests 
itself, can we aid this process of solution by means which oxygenate the 
blood more highly than can be done merely by free respiration of pure 
air? I have before surmised that it is probable that such agents as 
nitric and nitromuriatic acid and chlorate of potass, may contribute to 
this object; and I now mention them because I have found their con- 
tinued use beneficial in many cases after inflammation, in which circu- 
lation and absorption were slack, and cacoplastic effusions were accu- 
mulating and threatening mischief. So likewise in scrofulous and 
tuberculous disease, during the maturation and softening of the deposits, 
these oxygenating medicines sometimes produce decided improvement 
in the general and local symptoms. Their utility is limited by their 
tendency to irritate the alimentary canal when given largely or continued 
long; but they may commonly be advantageously used at intervals, when 

* [The evidence in favor of the curability of phthisis seems to accumulate and to in- 
spire us with fresh hopes and new expectations. Laennec first showed on pathological 
grounds that pulmonary tubercular cavities were susceptible of cure ; and the observations 
of Andral are confirmatory. Boudet states that he met with fourteen cases in the space of 
a year, in which there were all the evidences of softening and of the presence of a cavern, 
which had ultimately disappeared. Another mode of cure is by the retrocession of tubercle, 
and its conversion into calcareous or pultaceous concretions (§ 556). Dr. Hughes Bennett 
lias attempted to show that the cure of phthisis in this way is more frequent than is generally 
thought ; and he supports his opinion by numerous statistical data (a). Dr. Leeper says that, 
" during a period of six months, while acting as pathological assistant in the Edinburgh Uni- 
versity, he noticed the presence of these cretaceous remains in the lungs of nine individuals 
who had died in the Royal Infirmary of other diseases." Dr. Blakiston has reported several 
cases of the complete arrest of phthisis, not only after unequivocal signs of solid deposit at 
the summit of the lungs, but in which actual cavities had existed during life. See his 
valuable work on Certain Diseases of the Chest. Philadelphia, reprinted, 1848. — C] 



(a) Edin. Med. and Surg. Journ., No. 163, April, 1845, p. 406. 



MORBID GROWTHS — NON-MALIGNANT. 



315 



courses of cod-liver oil or of iron and other tonics are interrupted. 
Further details belong to special pathology and treatment. 



MORBID GROWTHS. 

569. Under the term morbid growths or tumors, may be arranged 
certain structures developed in the animal bodym addition to the natural 
textures. They differ from hypertrophy and euplastic deposits in the 
peculiarity of their structure; and from cacoplastic and aplastic deposits, 
in their possessing a higher degree of organization. In other words, 
they differ from hypertrophy and euplastic formations in their kind of 
vitality; and from degenerations and cacoplastic deposits, in their degree 
of vitality. They are, in fact, new structures; and although some of 
them in general characters, and most of them in elementary compo- 
sition, resemble some of the natural textures of the body; and although 
all derive their nourishment from the blood ; yet, in their origin and 
growth, they are more essentially distinct from the natural structures 
than are any of the results of diseased nutrition hitherto considered. For 
these reasons, they have been called new and parasitical growths; and 
the term parasitical is the more applicable to them, because their exist- 
ence and mode of growth cannot generally be traced to variations in the 
local circulation, which we have found to be chiefly concerned in pro- 
ducing and influencing the modifications of nutrition hitherto noticed. 

Morbid growths have been divided into analogous, those whose struc- 
ture resembles some natural texture (including false membranes, &c.) ; 
and non-analogous, or heterologous, those which have no parallel in the 
healthy state of the animal economy. But this division is inconvenient, 
because it is applied to the other products of diseased nutrition previously 
arranged under another division (hypertrophy and deposits); and it is 
often inapplicable, inasmuch as many morbid growths are essentially 
compound, comprising some forms that resemble natural textures, others 
that do not; yet all these are constituted of similar elementary molecules ; 
this remark especially applies to carcinoma. 

The division which I have adopted into non-malignant and malignant 
is more useful in a practical point of view, although it may not be easy 
to make it precisely applicable to all cases. 



SECTION VII. 

NON-MALIGNANT GROWTHS. 

570. I would apply the term non-malignant to those growths or 
tumors w T hich occur in a part of the body, without tending to infect 
other parts; and which arise among, but do not invade or penetrate the 
natural structures; and, if they prove injurious, it is by their bulk or 
position, or by the extent to which they abstract the nourishment of the 
body. 



316 



STRUCTURAL DISEASES. 



571. The most simple forms of new growth are serous cysts, which 
consist of a shut sac, "containing serum, and formed of condensed cel- 
lular substance resembling serous membranes, which are formed gradu- 
ally around a clot of blood, or any foreign substance in the system; and 
are frequently developed spontaneously in various parts of the body. 
They are frequently attached to the natural serous membranes, but some- 
times quite separate from these; sometimes solitary, sometimes set toge- 
ther in clusters; and their size and shape are very various. They must 
be distinguished from enlargements of natural cavities, such as the 
calices of the kidneys, or Graafian vesicles in the ovaries. They are 
often unconnected with disease of the adjacent textures; but in some 
cases, these textures are found either wasted by absorption (atrophy 
from pressure, § 532), or disorganized by inflammation around them. 
There is no evidence of their being generally connected, in their com- 
mencement, with inflammatory action ; and when they are small, their 
existence is often not denoted by any symptoms whatever."* 

Besides the instances above excepted from this class of new growths, 
may be mentioned several others, which are rather instances of hyper- 
trophy, dilatation, or unusual development of a natural structure, and 
therefore belong to a former division (§ 528). The enlarged bursas, in 
parts subjected to pressure; the dilated mucous follicles, in the cervix 
uteri ; the cutaneous follicles distended with fatty or other matter (epi- 
dermis scales), constituting the subcutaneous adipoma and melliceris ; 
the salivary ducts obstructed, and filled with concretion, in the tumor 
called ranula, are of this kind, and do not belong to the present division. 
I would, with Dr. Hodgkin, extend the same remark to the small serous 
cysts frequently found in the kidneys and liver, which I have before de- 
scribed as portions of secretory ducts obstructed and distended with 
serum, (p. 193, note.) It may be fairly questioned whether other serous 
cysts are not also due to enormous enlargement of the primitive or com- 
pound cells of which textures are partly composed. My friend, Dr. 
Hodgkin, has most plausibly advocated an opinion of this kind, and has 
applied it also to explain the production of more solid and complex 
growths, by the formation, multiplication, and compression of a series of 
cells. f 

572. Cysts, somewhat like the serous cysts above described, are some- 
times found filled with different unorganized contents, and then consti- 
tute the simplest kind of encysted tumors, which form in various parts of 
the body that have a cellular structure, and they have received names 
descriptive of their contents : — hygroma, when they contain a nearly 
serous fluid, and form encysted dropsy, if they attain a large size; hamar- 
toma, when their contents are bloody; steatoma, or lipoma, when they 
are of a fatty nature ; and atheroma, when they contain an opaque pulpy 
matter of piaster-like appearance. 

These cysts are probably often formed in the first instance of extra- 
vasated blood or fibrinous matter, the exterior of which becomes organ- 
ized into a sac, the inner surface of which, according to Vogel, secretes 
an epithelium; whilst the interior is more or less removed, and either 

* Alison's "Outlines of Pathology," p. 201. 
f Med. Chir. Trans., vol. xv., part 2. 



NON- MALIGNANT GROWTHS CYSTS, ETC. 



317 



gives place to serum, which may be more or less thickened by epithelium 
scales, or may become converted into fatty, or even osseous matter, in 
the same manner as aplastic deposits (§ 561), and the contents of old 
abscesses.* When such tumors form under the skin, they often contain 
epidermis scales, which may render their fluid opaque and thick, or by 
agglutination may concrete into a horny solid. In the vicinity of hairy 
parts, they often contain hair. In some instances cholesterin has been 
found in them in great abundance; not only in cysts connected with the 
liver, but in those large and often compound cystiform tumors connected 
with the ovaries. In these last organs, cysts have also been found en- 
closing perfectly formed teeth and bones, as well as hair. 

573. Complex cystiform tumors are more complicated in their structure, 
and exhibit further deviations from the natural organization. They are 
chiefly developed in connection with glandular organs or those having 
cysts or vesicles, as the ovaries. 

A still more complex and organized kind of tumor is that generally 
designated by the term sarcomatous, which consists of organized solids 
of considerable variety, but generally bearing a resemblance to one or 
more structures naturally existing in the body, and generally in the part 
in which the tumor grows. Thus we have fibrous tumors, consisting of 
densely compacted fibres, scantily supplied with blood-vessels, generally 
slow in their growth, and like fibrous deposits liable to ossification. 
Steatoma, or adipose sarcoma, which resembles natural adipose texture, 
but is often rendered more dense by combination with a fibrous structure ; 
— Chondroma, or cartilaginous tumor, which forms rounded masses 
having much analogy to cartilage, but may also be combined with bands 
of fibrous texture, and are liable to ossification; — Vascular tumors, (He- 
matoma, erectile tumors,) which consist of a congeries of blood-vessels 
of considerable size, apparently enlarged capillaries, with more or less 
connecting filamentous tissue. These last present varieties dependent 
on the freedom with which they communicate with arteries; when sup- 
plied by large arteries they are florid in color, they pulsate, and if large, 
the pulsation is attended by a blowing or rasping sound as in vascular 
bronchocele : when the arterial communication is not free, the tumors 
exhibit the darker hue of venous blood. f 

Dr. Hodgkin considers that the complex cystiform tumor, as it occurs 
in the ovary, exhibits a type of the origin of morbid growths in general, 
not excepting those of a malignant kind. From the internal walls of 
one original or parent cyst, there spring a number of other cysts, vary- 
ing in their contents, and as they grow T , they fill the original cyst, and 
project beyond it, other cysts being produced within them, and thus a 
growth takes place, subject to modifications from the nature of the tex- 
ture w T hich is its seat, as well as from the contents of the cysts. In solid 
structures, as dense cellular membrane, the cysts are so compressed as 

* Vogel suggests that similar cysts with various contents may originate in old abscesses 
which have never opened, and the pus in them has gradually undergone a change. Cysts in 
the liver, containing a gelatinous, and in some instances a putty-like matter, commonly pass- 
ing for tubercle, appear to have been produced in this mode. 

\ For further particulars respecting the pathological character of tumors, see Vogel's Pa- 
thological Anatomy, by Dr. Day, [Philadelphia, reprinted, 1847.] 



318 



STRUCTURAL DISEASES. 



to present the appearance of fibres radiating from a centre, and they 
lose all their liquid contents. The adjoining textures, as well as the 
walls of the cells, may also inflame and cohere, so as to obliterate the 
cystiform structure of the tumor. 

574. The pathological cause of morbid growths is involved in much 
obscurity. We cannot at present go beyond the supposition that they 
arise from altered vital properties in some of the molecules of the textures 
in which they are developed ; so that, instead of being assimilated to 
these textures, and conforming to the laws of their growth and decay, 
these molecules grow of themselves in modes more or less peculiar, and 
more or less independently of the influences of the adjoining living parts. 
Where these modes are less peculiar and more dependent on the nutri- 
tion of the adjacent structures, the growths are less abnormal, vary less 
from these structures, and in their origin and course more resemble either 
hypertrophy (§ 525) or euplastic deposits (§ 547), and they do mischief 
rather by their size or situation than from their intrinsic nature. Where 
the mode of growth is more peculiar and more independent of that of the 
textures in which they arise, the resulting tumors are more abnormal in 
their nature and mode of development; they approach in character to 
malignant disease, acting injuriously, not only by their bulk and position, 
but also by abstracting the nourishment of the body, and by tending to 
supersede the natural structures. 

575. At the outer limits of the non-malignant growths, maybe classed 
those peculiar bodies called hydatids or acephalocists. These are more pe- 
culiar in structure and contents than any other morbid growth, and they are 
quite detached from the structures in which they occur. They may, 
therefore, be inferred to possess a vitality quite independent of that of 
these structures. Their vitality is low, but indisputable, and is exhibited 
(1) in their power of self-nutrition, as manifest in the growth and the 
peculiar structure of their walls, w T hich are much more elastic than any 
normal animal texture; (2) in their power of secretion, shown by the 
peculiarity of their contents, which are limpid and colorless, whatever be 
the nature of the matter in the serous cyst which separates them from the 
living textures ; (3) in their power of reproduction by gemmation, the young 
being developed between the layers of the parent cyst, and thrown off, 
either internally or externally, according to the species. Professor 
Ow T en*. describes the hydatid to be " an organized being, consisting of a 
globular bag, which is composed of condensed albuminous matter, of a 
laminated texture, and containing a limpid colorless fluid, with a little 
albuminous, and a greater proportion of gelatinous substance." He 
adds — "As the best observers agree in stating that the acephalocyst is 
impassive under the application of stimuli of any kind, and manifests 
no contractile power, either partial or general, save such as evidently 
results from elasticity — in short, neither feels nor moves — it cannot, as 
the animal kingdom is at present characterized, be referred to that divi- 
sion of organic nature. It would then be a question, how far its chemi- 
cal composition forbids us to rank the acephalocyst among vegetables. 
In this kingdom, it would obviously take place next those simple and 

* " Cyclopedia of Anatomy," &c, article Entozoa. 



NON-MALIGNANT GROWTHS — HYDATIDS. 



319 



minute vesicles which, in the aggregate, constitute the green matter of 
Priestley, (protococcus viridis, Jigardh;) or those equally simple, but 
different colored psycho diaries, which give rise to the red snow of the 
arctic regions [protococcus kermesianus). These, first-born of Flora, 
consist, in fact, of a simple transparent cyst, and propagate their kind 
by gemmules developed from the external surface of their parent." 

The researches of Schleiden, Schwann, and their followers, have 
thrown some light on the possible origin of hydatids, by showing that 
the primitive cells of animal, as well as of vegetable, structure, are often 
not unlike hydatids in their anatomical composition, growth and mode 
of reproduction ; for the hydatid appears to be a nucleated cell, from the 
interior of which are developed nuclei and nucleoli, the germs of young 
cells. But if it be presumed, in accordance with this fact, that hydatids 
are really offsets of living structures, capable of living detached from 
the solids of the body, it still remains a mystery how this divided or- 
detached life is acquired by certain molecules on rare occasions, and 
contrary to the usual law. We might, perhaps, imagine some analogy 
between hydatids and the polype tribe of animals, which may be inde- 
finitely propagated by division ; and it might be conjectured, that the 
conditions of the body in which hydatids are most commonly found, 
might reduce the plasma of certain parts to the standard of this mode 
of life; but these subjects are too speculative to be dwelt on here. 

576. The situations in which hydatids have been most commonly 
found, are the liver, the lungs, the spleen, the kidneys and the ovaries. 
M. Andral records an instance in which he found hydatids in the blood 
within the pulmonary veins ; there was also a large cyst, full of hydatids, 
in the liver. The condition of the system in which they have been most 
frequently found to occur, is one of cachexia and mal-nutrition. They 
are usually contained in a serous or protective cyst(§ 571), formed by 
the texture around them ; and the symptoms which they occasion are 
merely those caused by their bulk and position, compressing, displacing 
and irritating organs, and causing atrophy and inflammation of their 
textures. In the cyst which contains them, there is commonly found 
more or less opaque laminated matter, which appears to be the debris 
of collapsed hydatids; indeed, some of them retaining the globular form, 
often exhibit the commencement of this decay, in an opacity and wrin- 
kling of their walls, and a changed color of their contents. But I have 
likewise found a considerable quantity of an opaque, yellowish, pulta- 
ceous matter mixed with the collapsed hydatids, and lining the contain- 
ing cyst ; under the microscope it appeared to consist of granular mat- 
ter, and imperfect cells, with much fat, and in one instance, where the 
hydatid's sac lay between the liver and the diaphragm, there were abun- 
dant crystals of cholesterin ; I therefore regard this opaque matter as a 
deposit from the surface of the sac, degenerated into aplastic and fatty 
matter. 

577. The echinococcus is a variety of hydatid, differing from the pre- 
ceding chiefly in its having a yellowish and tougher outer tunic, and in 
its containing distinct animalcules within it (vermiculus echino cocci). It 
has been found in the liver, spleen, mesentery and substance of the 
heart, and rarely in the urine. The cysticercus is found in muscular 



320 



STRUCTURAL DISEASES. 



structure, and in one instance was seen in the aqueous humor of the 
eye. It has a distinct structure, consisting of a cystiform body and a 
head provided with suckers and hook-like processes for attachment. The 
distoma hepaticum, or liver-fluke, is rarely found in the human subject. 
It is the supposed cause of the rot in sheep, and was found by Andral 
and Delafond in those animals in which dropsy was present, and there 
was a defect of albumen in the blood (§ 222). The rot is a disease which 
chiefly attacks sheep fed in wet clayey pastures. 

The subject of intestinal worms belongs properly to special pathology. 

578. Little can be said on the medical treatment of morbid growths. 
To those of the kinds most approaching to the natural textures may be 
extended the observations applied to hypertrophy (§ 529) and euplastic 
deposits (§ 552). So far as they originate from, or are augmented by, 
local determination of blood, or any other kind of hypersemia, the reme- 
dies for these morbid elements may retard the increase of the growths. 
But as we have found that the chief peculiarity and cause of these growths 
is an alteration of the vital properties of the primitive molecules of tex- 
tures, little is to be expected from measures which act only on the quan- 
tity of the nutritive material. In fact, we have seen that, in many in- 
stances, morbid growths seem to originate in connection with a depressed 
rather than with an exalted condition of the vascular functions ; and in 
those last noticed, which bear more distinctly the character of parasites, 
the general or constitutional powers are weakened in proportion as these 
are developed. Hence, the general treatment indicated in such cases is 
of the supporting and tonic kind, with due attention to the regulation of 
the digestion and of the secretion. But this treatment will require modi- 
fication when the morbid growths, by their irritation or pressure, excite 
a considerable amount of inflammation, or even of local obstruction to 
the circulation. 

We are not acquainted with any medicinal means of correcting those 
alterations of vital properties in the molecules or textures from which 
morbid growths take their rise. The same spontaneous power which 
places these growths beyond the controlling influence of the laws of tex- 
tural nutrition, removes them beyond the reach of general remedies. 
The surgeon can in some instances remove the diseased part by the 
knife, and can sometimes further modify its properties by the direct 
application of escharotics or caustics, which destroy the morbid cells or 
germs which are the roots of the growth ; and where this can be effectu- 
ally done without serious injury to other living parts, the cure maybe 
complete. Mechanical pressure carefully and steadily applied so as to 
diminish the supply of blood to the tumors without interrupting the circu- 
lation in other parts, has sometimes been effectual in restraining the 
increase, and in some cases in promoting the absorption of morbid 
growths. It is doubtful whether the physician possesses any means of 
aiding the surgeon in these cases, or of controlling morbid growths which 
are beyond the reach of the surgeon, further than those calculated to 
promote the general health of the body. 

In many instances, the secondary pathological changes induced by 
morbid growths, such as inflammation, congestion, dropsy, flux, &c, 



MORBID GROWTHS, MALIGNANT. 321 

are the chief objects of treatment, and may often receive much benefit 
from the usual remedies; but the extent of this benefit is commonly 
limited, as to extent and time, by the permanency and intractability of 
the morbid growth, which is their cause. Thus with encysted dropsy of 
the ovarium, peritonitis, ascites, and oedema, obstruction of the intestines, 
and other secondary functional disturbances, generally admit of relief for 
a time; but as the ovarian tumor remains, and may increase in spite of 
all remedies, the resulting disorders recur again and again, and at last 
prove fatal. But the growth of the cysts themselves, although generally 
progressive, may be very capricious — being sometimes very rapid ; in 
other instances, even in the same case, it may remain stationary for 
years. Nay, cases are not wanting, although rare, in which encysted 
tumors have altogether disappeared: as after the operation of tapping, 
or even spontaneously, by rupture, into some of the natural cavities. But 
such instances, although they show a variety exhibited by morbid 
growths, not to be forgotten in connection with prognosis as well as 
treatment, are to be considered rather as exceptional cases, than as those 
following the usual rule. 



SECTION V1IL 

MALIGNANT GROWTHS. 

579. Malignant growths are distinctly organized structures, arising 
in various textures of the body, invading these and contiguous textures 
with their own peculiar substance, and often appearing successively or 
simultaneously in several parts of the body. There is perhaps no cha- 
racter more indicative of malignancy than the disposition to pervade 
and penetrate the several structures of a compound organ, and even to 
form attachments to those adjacent, and thus to unite several distinct 
textures and even organs into one morbid mass: in this respect they 
contrast with non-malignant tumors and deposits, which push aside, 
compress, or distend the structures in or near which they are developed, 
but never penetrate through them. Malignant growths thus prove in- 
jurious, and eventually fatal, not merely by their bulk and position 
(§ 569), but also by the change of structure which they may induce in 
various organs; by the intractable ulcerations and fungous wounds to 
which they tend; and, lastly, by a wasting and deleterious influence 
which they seem to exercise on the whole functions and structures of 
the body. In all these points, the most malignant growths exhibit a 
character perfectly distinct from the more simple, harmless growths, 
hitherto described ; but it must be observed, that the degree of malignancy 
varies very much in different cases, by one or more of the preceding 
characters being absent, or not yet well developed; and consequently, 
that morbid growths or tumors are occasionally met with, which present 
a doubtful or intermediate character between non-malignant and malig- 
nant. 

580. The names cancer and carcinoma (from the supposed resemblance 
21 



322 STRUCTURAL DISEASES. 

of the diseased structure to a crab, cancer, xapxivo$, which suggests 
the apt image of numerous claws penetrating and attacking adjacent 
parts), have been long applied to the whole genus of malignant growths, 
which comprehends the following varieties: — Scirrhus ; ?nam?nary, pan- 
creatic, and solanoid sarcoma; encephaloid or medullary sarcoma-, fungus 
hcematodes ; and colloid or gelatinous cancer. That these are all varieties 
of the same disease may be inferred from the fact, that they more or less 
resemble each other in the characters of malignancy above described; 
and that they frequently occur in the same subject, either simultaneously 
in different parts, or successively in the same part. Thus a person who 
has long been affected with scirrhus of the breast, often dies with me- 
dullary sarcoma in the liver or lungs; or after a scirrhous tumor has 
been removed from any external part, an encephaloid or fungous disease 
may subsequently appear in its place. The varieties may, for the most 
part, be traced to different degrees of activity in the specific or cancerous 
matter, that may now be stated to be the materies morbi, and to the 
varied changes in the new growth, and in the implicated textures which 
this matter, thus differently active, can produce. Of these varieties, it 
may be said generally, that scirrhus, and perhaps the mammary and 
pancreatic sarcoma, exhibit a chronic character, w r ith less activity and 
tendency to increase locally, or to spread through the system ; whilst the 
others constitute the more acute forms of cancer, causing more rapid 
growth in the parts first affected, and more speedily appearing in other 
parts of the body. 

581. The peculiar matter of cancer is distinctly a structure, consist- 
ing of nucleated cells and molecules, contained in an areolar or fibrous 
web of very various density. Of these, the cells must be considered the 
first elements; and although they present some variety in form, they are 
constantly found in every kind of cancer. These cells are chiefly globu- 
lar, and retain that shape in the soft, gelatinous kinds of caneer; but in 
others, many are caudate or spindle-shaped, as if in the process of trans- 
formation into fibres. Into scirrhus, and other more solid and chronic 
forms of cancer, the fibrous structure is more abundant, and is very per- 
ceptible to the naked eye, forming glistening striae or bands radiating 
through the mass, of cartilaginous hardness; the cancerous cells and 
numerous granules are seen between these fibres, and accompany them 
to their outermost branches. In the cerebriform or medullary kind of 
cancer, the nucleated cells are very numerous; and the texture in which 
they are contained is cellular, and well supplied with vessels. This is 
the species in which the growth is most rapid, and in which, from the 
extravasation of blood in the loose new texture, a bloody aspect is given 
to parts of it, whence the name fungus hcematodes. 

582. The intrinsic disposition to grow, even at the expense of the 
nutriment of other parts of the body, which was mentioned to be a cha- 
racter of some formations not distinctly malignant (§ 574), is exhibited 
in a much higher degree in malignant structures, the increase of which 
may take place most rapidly when all the natural textures are wasting 
away. This fact again suggests the idea of an independent vitality pos- 
sessed by these structures, in virtue of which, like parasitic animals or 
plants, they luxuriate at the expense of the whole frame. The question 



MORBID GROWTHS, MALIGNANT — CANCER. 



323 



next arises — Are these growths truly parasites, arising from ova or seeds 
derived from without the body, and after entering it, and finding a pro- 
per nidus or soil, taking root or becoming developed as a distinct being, 
like worms or hydatids, and drawing its nourishment from the fluids and 
solids of the body? If it be objected that malignant growths are too 
closely attached to, and too much identified with, the textures of the 
body to permit the notion of a distinctness of being, it may be replied, 
that cancerous cells, their most distinctive part, are often loose and unat- 
tached: they propagate themselves by the production of young cells 
within them : and in this mode become disseminated, first in contiguous 
parts, in which they appear to take root and extend their attachments ; 
and subsequently, through the channels of the blood-vessels, which in 
extensive forms of the disease have been found to contain cancerous 
masses. An experiment of Professor Langenbeck was supposed to 
have proved that the cancerous pulp containing these cells is capable of 
propagating cancer in animals on being injected into their veins, but 
the attempt has been frequently made by others without any such result. 
Should such an experiment be made to succeed, it would positively iden- 
tify cancer with contagious diseases, respecting the causes of which we 
formerly noticed questions like the present, as to their parasitic nature 
(§ 99). Contagion is not, however, a common cause of cancer; the only 
example ever adduced being the rare one of the penis becoming infected 
by a carcinomatous os uteri. Further, it has been well remarked, by 
Dr. W. Budd,* that the causes which have been supposed to induce can- 
cer are not such as can, in any intelligible way, favor the introduction of 
germs from without the body. Thus, in chimney-sweeps and others, 
the continued application of soot has been observed to be followed by 
the occurrence of cancer in the scrotum, in such a number of cases, as 
to justify the inference, that it has been the exciting cause. The often 
repeated contact of a tobacco-pipe with the lip, has also been considered 
a cause, of cancer of that part. But neither of these causes can, in any 
conceivable way, promote the development of cancer from extrinsic 
germs. 

The alternative that presents itself is, that cancerous growths may 
arise from a peculiar perversion of the natural nutritive process, similar 
to those modifications which we have been induced to suppose are the 
causes of the more peculiar kinds of common growths; but in the case 
of malignant disease, the perversion is much greater in degree, and 
shows itself, not only in its origin, but in its whole subsequent history. 
It can be conceived possible, that causes long acting locally, as the soot 
on the scrotum of chimney-sw r eepers, the tobacco-pipe on the lips of 
inveterate smokers, the irritations of the stomach connected with habitual 
dyspepsia, and of the uterus from irregular menstruation, &c, may 
induce this extraordinary alteration in the molecular nutrition of these 
parts; but we cannot hereby at all explain the peculiarity of this altera- 
tion, which must therefore be viewed as an ultimate fact in connection 
with nutrition. In others words, if we assume that cancer cells are mo- 
difications of the natural cell-germs by which textures are produced and 

* Remarks on the Pathology and Causes of Cancer, Lancet, May 28, 1842. 



324 



STRUCTURAL DISEASES. 



nourished, we do not thereby explain (or refer to a known law) the ex- 
traordinary, anomalies of the independent vital properties and consequent 
growth of these modified cells, which are obviously different from that 
of texture cells in general, and derive much of their destructive effects 
from such difference. It remains for future investigation to establish 
the law of that difference. We have before stated, that Dr. Hodgkin 
has proposed a plausible hypothesis with regard to these and other 
growths, that they originate in cysts (not cells or microscopic cysts, but 
larger ones, which comprise these): and that the multiplication of these 
cysts within each other, their prolongation into radiated fibres, their 
pressure on adjoining textures, and consequent inflammation, induration, 
ulceration, atrophy, or gangrene of these textures, comprise the whole 
history of malignant growths. What appears to me to be chiefly want- 
ing to establish Dr. Hodgkin's view T s, is a more distinct demonstration 
of the supposed cysts, which, at the commencement, or at the outer 
limits of cancerous growths during their spread, ought to be distinctly 
visible. 

583. But although the precise origin of malignant growths is still a 
matter of uncertainty, some important practical facts may be gathered 
from their pathology. Their microscopic structure and history pretty 
clearly show that they are of local origin ; that they extend by the mul- 
tiplication of their cells, which, by perverting the nutrition of the adja- 
cent parts, cause the growth of the tumour; that they ultimately infect 
other parts of the body, by spreading to the nearest lymphatic glands, 
and by the mixture of their cell-germs with the blood (§ 259), which 
form new r tumors in the liver, lungs, or other vascular parts, (the same" 
as those in which purulent deposits take place, and for similar reasons) 
(§ 470); or the cancerous matter is sometimes found in clots within 
blood-vessels, or in the coagulable lymph effused by inflammation.* 

But the history of malignant growths comprises not only that of the 
development of the cancerous structures in different degrees, and forms, 
but also their effect on. the adjacent textures; and it seems to me possible 
by a due regard to these two elements, to explain much of the varieties 
which cancerous disease presents. Thus scirrhus is the slowest form of 
the disease, because it generally occurs in persons above the age of forty, 
in w T hom the textural nutrition is tardy, and the cancerous matter is but 
slowly developed: the effect on the adjacent textures is to excite inflam- 
mation of a chronic form, and therefore leading to induration, and often 
to contraction (§ 479), and more or less obliteration of the natural tex- 
tures. Hence the hard, knotty, corrugated swelling of scirrhus of the 
mamma, rectum, pylorus, &c, which may be attended with more or less 
pain of a peculiar stinging or lancinating character, besides various 
functional disturbances, (obstruction to the passage of food or feces, 
severe dyspepsia, vomiting, &c.) The continuance of irritation in the 
indurated parts leads (as usual) to ulceration (§ 466). This constitutes 
what is called open cancer, with ragged, inverted, or everted edges, and a 

* In a case (which I saw with Mr. Avery) of malignant disease of the lungs and deep 
cervical glands, involving the 8th nerves, there had been recent pleurisy, and the bands of 
false membrane were glistening, and grated under the scalpel from the presence of cancerous 
fibres. 



MORBID GROWTHS, MALIGNANT CANCER, 



325 



fungous or sloughy interior, discharging a dark, offensive, ichorous mat- 
ter. That such ulcers should be wholly incapable of healing is quite 
intelligible, when it is remembered that its walls are composed of the 
cancerous structure and the compressed remains of the natural textures, 
whose secretions are too poor and to much perverted to afford euplastic 
secretion. The ulcer may prove an outlet for the increasing cancerous 
matter; and if the discharge be checked by external means, the disease 
is more likely to spread or to attack other parts: as the ulceration destroys 
the indurated mass, and thus removes the barrier between the cancerous 
germs and the healthy textures, there is a greater chance of the body 
becoming more generally infected. Hence, too, from the multiplication 
and diffusion of the germs, the secondary malignant growths that may 
appear in other parts are often of the softer, more rapidly growing kinds. 
The influence of scirrhous cancer on the whole frame, although more 
slowly induced, perhaps for this very reason, is carried to a greater degree 
than that of any other form of cancer. Emaciation sometimes reaches 
a point unequaled in any other disease ; and the wasting, of which this 
is the sign, extends to the composition as well as to the bulk of organs 
and textures. Thus bones lose much of their animal matter, and become 
so brittle, as sometimes to be fractured from the slighest violence. All 
membranes become extremely thin; the omentum often wastes away, 
excepting a few threads. The lungs exhibit a remarkable lightness, in 
weight and color; and I have seen the old cicatrices or consolidations, 
so frequently found at their summits, thinned and almost as pliant as other 
parts of the pulmonary texture.* But nothing is more remarkable than 
the ex-sanguine state of the textures generally; and this condition is 
obvious during life in an extreme pallidity, often associated with a sal- 
lowness or peculiar lemon-tint of complexion, that has been observed to 
be peculiar to cancerous subjects. 

Scirrhus chiefly occurs above the age of forty; and the more advanced 
the age, the slower generally is the progress of the disease. It has been 
remarked, by Sir Charles Bell, Sir Astley Cooper, Mr. Travers, and others, 
that scirrhus of the breast, which will run a comparatively rapid course 
at the age of forty-five, will remain stationary for years, and hardly ap- 
pears to shorten life at the age of sixty or seventy. This shows the 
share which activity of textural nutrition has in causing the increase 
and dissemination of cancerous disease. It is under such circumstances 
that operations for the removal of the disease have been most successful ; 

* It appears to me, that the rare co-existence of tubercle with cancer, as noticed by some 
writers, is to be ascribed to the former being removed by absorption, during the extraordinary 
wasting of textures which attends chronic cancer. I have twice found, in the bodies of 
persons who died of cancer, considerable remains of tuberculous deposit at the apex of the 
lungs, without any tubercles in other parts. In one case, masses, partly caseous, partly 
calcareous, of the sizes of a pullet's and a pigeon's egg, were thus found encysted by a thin 
membrane. In another, a cavity communicating with the bronchi, traversed by a band of 
dense tissue, like that fouud in tuberculous cavities, and lined with a thin, smooth .mem- 
brane, was in the middle lobe. In all these cases, the other parts of the lungs were free 
from tubercles. Now, it does not appear probable that such considerable tuberculous deposit 
should have taken place without some in other parts also. We meet with no case of recent 
tubercle thus limited to one portion of the lung. These and similar facts connected with the 
emaciation of old age, seem to me to furnish additional arguments in favor of the absorp- 
tion of tubercles (§ 56 1). 



326 



STRUCTURAL DISEASES. 



but it must be remembered, also, that in such cases they are less strongly 
called for. 

584. The pancreatic, mammary, lardaceous, (or pork-like,) and solanoid, 
(or potato-like,) forms of cancer appear to be intermediate between 
scirrhus and encephaloid disease, increasing more rapidly than the former, 
yet approaching to it in firmness. They are attended with less pain, 
from the smaller degree of tension and induration which they cause in 
the implicated textures. For the same reason, they are less disposed to 
ulcerate (§ 466) or slough (§ 474); and they commonly prove fatal, 
either by their growth and encroachment on some vital part, or by lead- 
ing to the dissemination of cancerous deposits in other parts of the sys- 
tem. 

585. Encephaloid, (brain-like,) or medullary sarcoma, is the acute or 
rapid variety of cancerous growth. It occurs chiefly in young and mid- 
dle-aged subjects, and in the most vascular textures; and it maybe 
fairly connected with the activity of their molecular nutrition. This 
may be the cause of the rapid increase of the cancer-germs or cells, (if 
these be indeed mere modifications of the cell-germs of textures ;) and 
their elongation and growth into remarkably large and sometimes branch- 
ing fibres, forming the stroma or web of the cancerous growth; but much 
of the speedy increase and early dissemination of this variety of cancer- 
ous disease, must be attributed to an active plastic process, which the 
presence of the cancerous matter excites in the vascular textures f in 
which it 'lies. The mass of encephaloid tumors comprises false mem- 
branes, lymph, and even coagula of blood, in various degrees of organi- 
zation ; among and between these are found the cancerous cells and 
fibres, which luxuriate and rapidly multiply in so fertile a soil. It is in 
connection with tumors of this kind that the fact before noticed has been 
observed, that coagula in the neighboring veins have exhibited the ence- 
phaloid appearance; and so has coagulable lymph, produced by inflam- 
mation of serous membranes or parenchymata of organs. The speedily 
destructive influence of this kind of cancer is mainly to be ascribed to 
the rapid dissemination of the cancerous matter, and the bulky deposi- 
tion which it induces around it, which, although organized, and highly 
vascular, are beyond the controlling influence of the powers of assimila- 
tion or absorption, and consequently penetrate, obstruct, or compress 
organs to a fatal extent. The facility of growth in these tumors receives 
some explanation in the varicose condition of their vessels, as ascertained 
by Mr. Kiernan, and their free communication with arteries (§ 420), as 
pointed out by Schroeder Van der Kolk. The same circumstance, to- 
gether with the general softness and looseness of their texture, accounts 
for the facility with which hemorrhage takes place into their substance 
(§ 357), causing an appearance that has led to the use of the term fun- 
gus hcematodes. These forms of disease commonly prove fatal before 
the emaciating effects, so remarkable in scirrhus, have advanced far. 

586. The colloid or gelatinous {areolar of Cruveilhier) variety of can- 
cer seems to me to represent the cancerous element almost in a separate 
state, little mixed with natural tissues or their products. According to 
Miiller, it consists chiefly of cells contained in -a very slight loose web ; 
the cells are larger and rounder than usual, and contain small cells, 



MORBID GROWTHS, MALIGNANT — CANCER. 



327 



which also contain cell-germs. The peculiar germinal principle of can- 
cer is here, therefore, very abundant and prolific; but the nutritive se- 
cretion of the surrounding textures is not equally copious ; therefore no 
distinct growths are formed ; but the gelatinous matter is found infil- 
trated into the webs of textures, chiefly in connection with advanced 
stages of other forms of the disease. 

Further varieties have been described, by Dr. Carswell and others, 
according to the particular form which the cancerous growth assumes, 
such as the tuberiform, stratiform, ramiform, &c. They are probably 
connected with the anatomical construction of the parts in which they 
appear, together with the quantity and rapidity of development of the 
new growth.* 

[In the very interesting paper of Dr. Hughes Bennett, in the Edin- 
burgh Monthly Journal, the anatomical characters of cancer are thus 
described. A cancerous growth may contain the following elementary 
structures: 1. Molecules and granules; 2. Nucleated cells of various 
shapes; 3. A filamentous or fibrous tissue; 4. A viscous fluid; 5. Blood- 
vessels; 6. Fatty matter; 7. Pus, and compound granular cells; 8. 
Black pigmentary matter; 9. Earthy matter. Of these some are acci- 
dental or only occasional, and others essential or invariably present. 
The essential elements of cancer are — 1. A fibrous meshwork or stroma; 
2. Nucleated cells; 3. A viscous fluid in which these float. 

The fibrous tissue of cancerous growths exactly resembles that found 
in lymph, or in the healthy tissues of the economy. It may be formed 
either by deposition or, by means of celi-growth. In the former case, 
filaments more or less delicate, and closely aggregated, may be seen 
crossing each other, or running in bundles, forming various kinds of 
mesh-works, in which the cells of cancer are deposited. In the latter 
case we can observe fusiform cells splitting up into fibres, and are able 
to trace their formation from round, oval, or caudate cells, until perfect 
fibres are formed. These cells (called by Lebert fibro -plastic) are of a 
round or oval form, varying in size from the 1-1 00th to l-50th of a milli- 
meter in diameter. Sometimes they possess a distinct nucleus, about 
the ylo^h °f a millimeter in diameter; at others, contain only several 
molecules and granules. Acetic acid causes these bodies to undergo 
very little change. They become somewhat paler, but there is no marked 
difference in this respect between the nucleus and cell-wall. These 
cells, in their different stages of development into fibres, have been fre- 
quently mistaken for those of cancer. Midler placed them among can- 
cerous growths; and hence the erroneous opinion that the caudate or 
spindle-shaped cell is characteristic of cancer. Fibrous tissue may be 
arranged so as to form loculi, containing a viscous fluid with or without 
cancer-cells, constituting the colloid tissue of authors. 

The nucleated cells peculiar to cancer vary greatly in shape and size. 
Sometimes we see nothing but oval bodies about twice the size of a 
human blood-globule, or closely resembling, except in color, the oval 
blood-corpuscles of the lama or camel. They measure about the l-75th 

* Many interesting particulars respecting the microscopic characters of cancer will be 
found in Vogel's Pathological Anatomy, (by Dr. Day.) and in the Edinburgh Monthly Jour- 
nal, by Dr. Hughes Bennett, October and November, 1847. These have appeared since the 
publication of Dr« Walshe's elaborate Treatise on Cancer. 



328 



STRUCTURAL DISEASES. 



of a millimeter in length, and l-100th or l-120th of a millimeter in 
breadth. These oval bodies are the nuclei of cancer-cells. Sometimes 
they exist alone; at others we may observe, by careful management of 
the light, a round or oval delicate cell-wall, frequently resembling a mere 
shadowed halo, in the fluid in which it floats. On adding acetic acid 
to them, we find the cell-wall disappear, whilst the nucleus becomes 
more distinct than formerly. Such is the character of a cancer-cell in 
its young state. At a more advanced period of development, the cell- 
wall is more distinct. The nucleated structure is now round or oval, 
its medium diameter being about the 1 -50th of amillimeter, with a round 
or oval nucleus about the 1-lOOth of a millimeter in diameter. The 
addition of acetic acid always produces a remarkable change in these 
bodies, causing the cell-wall to become very transparent and faint, and 
the nucleus to assume an unusual degree of distinctness. Hence Dr. 
Bennett considers that Dr. Walshe has committed a fundamental error 
in his histology of cancer, when he says (p. 33 of his treatise) that "the 
ultimate microscopical cells of cancer are insoluble in cold and boiling 
water, and are not seriously affected by acetic acid." 

Dr. Bennett minutely describes the further growth of these cells, 
showing how they multiplied from cell rising within cell. It is owing 
to this cellular structure, that cancer owes the reproductive power 
which constitutes its malignancy. The cells occur insulated or in 
groups, surrounded by the other elements of the growth, but more espe- 
cially by the fibrous tissue. 

The third essential element in cancer is a gelatinous fluid. On 
cutting through a scirrhous tumor, however hard it may be, we may 
generally succeed in scraping from its surface a fluid more or less trans- 
parent. In soft cancer it is more abundant, and contains the granules 
and cells previously described. In some forms of cancer, however, it 
constitutes a very large proportion of the mass, presenting a gelatiniform 
or mucilaginous appearance, varying in color from a pearly white to a 
deep amber, and in consistence from a slightly viscous fluid to a firm 
semi-solid mass. Collections of this kind may occur in loculi formed by 
fibrous tissue, or in cystic tumors perfectly structureless, or containing 
only numerous molecules and granules constituting the simple colloid 
tissue of Gluge and Lebert. When associated with cancer, however, it 
contains a greater or less number of the cells previously described, in 
various stages of their development. 

It is the relative amount of the three essential elements of cancer 
now described which constitutes its peculiar form. If the fibrous ele- 
ment be in excess, it constitutes scirrhus. If the corpuscles be numerous, 
encephaloma is produced ; and if the fluid abound, and is collected into 
loculi, we call it colloid cancer. There is no other difference between 
these three forms than this. 

At an early period in the study of histology, it was natural to con- 
ceive that a certain form of the cell should be thought characteristic of 
cancerous growths. The observation of Miiller led to the belief that the 
caudate and spindle-shape of this minute structure was peculiar to them. 
Hence w T e find him confounding certain tumors long denominated sar- 
comatose, and which wholly consist of fusiform cells, with cancerous or 



MORBID GROWTHS, MALTGNANT — CANCER. 



329 



malignant growths. These, however, have no power of reproduction ; 
and, although often associated with cancerous cells, should not be con- 
founded with them. From the results of many examinations, Dr. Ben- 
nett is satisfied that there is no one form of cell which can be considered 
as at all times characteristic of cancer. The caudate and spindle-shape 
of these bodies is common to fibrous structures in general, frequently 
seen in lymph, and especially in the exudation forming the granulations 
on ulcers, recent wounds, vegetations on the endocardium, &c. &c. 

The structure of the cell and the action of acetic acid upon it are 
much more distinctive. If the corpuscles are in that stage of growth in 
which they present a distinct nucleus with contained nucleoli, and if, 
on the addition of acetic acid, their external wall be rendered more trans- 
parent, whilst the border of the nucleus is apparently thickened, they are 
highly characteristic of a malignant structure. But even this is not an 
absolute and invariable mode of distinction ; besides, it is only applicable 
when the cells have arrived at a certain stage of development. Dr. 
Bennett has frequently seen young epithelial cells, under certain circum- 
stances present all the characters just mentioned, w T ith the exception of 
inclosed nucleoli, and undergo the same reaction with acetic acid. This 
is very apparent in some cases, where effusion has taken place into the 
lateral ventricles of the brain, when the epithelial cells fo the choroid 
plexus become separated, swell out from endosmosis, assume a globular 
form, and the cell wall, if young, is partially dissolved in acetic acid, 
wmilst the nucleus is unaffected. The same occurs w T ith the epithelium 
of the bladder. He has found in the bladder a fluid having all the ex- 
ternal appearance of pus, and on examination shown them to consist of 
round, oval, and caudate nucleated cells, exactly resembling those found 
in cancer, and acting with acetic acid in the same manner. Yet the 
lining membrane of the bladder, the ureters, and kidneys, were perfectly 
healthy. We need not wonder then that epithelial cells have frequently 
been mistaken for those of cancer, even by histologists ; and that many 
growths, consisting of hypertrophy of the. epidermis, or epithelium, as in 
several so-called cases of cancer of the lips, ulcerated warts, excrescences, 
&c, should have been mistaken for malignant growths. 

Dr. Bennett states, that he is not aw T are of any tissue in which a fibrous 
and a cell-structure, such as has been described, were combined, and 
he is, therefore, inclined to think that whenever we find cells of this kind 
deposited between the meshes of a filamentous structure, we may be 
satisfied that cancer is present. If w 7 e trust to the form of the cell alone, 
we may confound epithelial growths with cancer — if we trust to the 
fibrous elements alone, we may mistake sarcomatous growths for it. But 
in no case, so far as his experience has yet gone, can the two be asso- 
ciated without the existence of malignant growth. This character, then, 
he thinks one which will apply to all forms of cancer. In many cases 
the form and appearance of the cells, to an experienced eye, will be 
sufficient; this more especially w 7 hen they are fully developed, and the 
influence of acetic acid upon them observed. In difficult cases the con- 
joined character of the cells and fibres, and their relative position with 
respect to each other, will enable us to determine the point with more 
exactitude. To arrive at a knowledge of these facts, however, consi- 



330 



STRUCTURAL DISEASES. 



derable skill in the manipulation of the microscope is necessary, and a 
very intimate acquaintance with the healthy and morbid tissues of the 
body. To distinguish the relative situation of the cells and fibres, espe- 
cially when mucous membranes are the object of investigation, a sec- 
tion, by means of Valentin's double-bladed knife, is also in most cases 
essential.] 

587. Another morbid production that has generally been classed 
among malignant growths, because it affects many textures and may 
supersede them, is melanosis, black cancer, or black tubercle. It most 
commonly occurs in the form of a loose cellular tissue filled with the 
peculiar black matter suspended in a serous liquid ; but sometimes its 
substance is quite compact and resembles crude yellow tubercle, or the 
lardaceous form of cancer. I have a drawing which I made of a lung 
exhibiting a combination of encephaloid. disease with melanotic tumors, 
the latter of compact texture, like nodules of pulmonary apoplexy, and 
varying in color from a dark bistre brown to a deep jet black. The 
combination of melanosis w T ith carcinomatous tumors has also been no- 
ticed by Cruveilhier and Carswell. Andral describes melanosis to occur 
in four forms: — "(1) It pretty frequently constitutes masses, encysted or 
otherwise; (2) the matter which composes it may, like the tubercular 
matter, be infiltrated into different tissues; (3) it may be spread like a 
layer, of greater or less thickness, on the free surface of membranous 
organs; (4) it may exist in the fluid state, either pure or mixed with 
other fluids."* 

The peculiar characteristic of all these forms is the black matter, 
which, from the analyses of Dr. Fyfe, M. Thenard, and M. Foy, ap- 
pears to be a highly carbonized insoluble matter, supposed to be altered 
coloring matter of the blood. It has been compared by Andral to the 
black pigment of the eye, and he considers it to be identical with the 
black matter commonly found in the lungs and bronchial glands. The 
coloring matter of the blood certainly is sometimes changed into a per- 
fectly black matter, as in the black vascular striae and patches in the intes- 
tinal canal, particularly in chronic inflammation where the blood has been 
effused or retained in vessels, and altered by the intestinal secretions 
and gases. These black appearances are called by Dr. Carswell spu- 
rious' melanosis. Again, the black pulmonary matter is merely a car- 
bonaceous powder contained in the interstices of the textures, and some- 
times in the vessels of the lungs and bronchial glands; but whether it 
also proceeds from the coloring matter of the blood in an altered state, 
or is truly a deposit of carbon, is uncertain. All that is requisite to pro- 
duce a black carbonaceous deposit in the coloring matter of the blood is 
the abstraction of a certain amount of hydrogen, which the mineral acids 
are capable of effecting; and it seems not improbable that such a change 
takes place naturally in the formation of black pigment through the ope- 
ration of peculiar cells (pigment cells), and as a result of disease in 
melanosis. 

But this production of black matter may coexist with various modifi- 



* "Pathological Anatomy, 11 (Transl.,) vol. i. p. 249. 



MORBID GROWTHS, MALIGNANT TREATMENT. 



331 



cations of the nutritive process; plastic, as in cellular and membranous 
melanose tumors; cacoplastic, as in the hard black tubercle, and in the 
black consolidation of chronic pneumonia; and aplastic, as in the com- 
bination of black with opaque caseous matter, not unfrequently found in 
the lungs and bronchial glands. So, too, it may be, as we have seen, 
combined with various forms of malignant disease; but, with Andral, I 
hesitate to class simple melanosis with malignant growths. 

588. The treatment of malignant disease has been generally considered 
to belong rather to surgery than to medicine, and yet the utility of re- 
moving malignant growths by operation, has been generally deprecated 
by surgeons down to the present time, when they may again learn, chiefly 
from the investigations of physicians, when and why operations may be 
expected to be successful. The indications of treatment which are sug- 
gested by the foregoing account of malignant disease, may be summed 
up under three heads: — (1) to extirpate the malignant growth ; (2) to 
retard its development ; and (3) to counteract its effects. 

The complete extirpation of malignant growths can be effected only 
when they are quite local, so that, when removed by the knife or by 
caustic, no root nor stray germs of the disease shall be left behind. We 
have adduced reasons to suppose that, at its first origin, cancer is entirely 
local, and that, if it be completely excised at an early period, a cure 
may be effected. For this success, it is essential that every cancerous 
cell be removed ; and Dr. Hodgkin has recommended the careful exa- 
mination of the portion removed, to see that it contains on its surface 
none of those grains, consisting of an aggregation of cancerous cells, 
which can be seen, even with the naked eye, in cancerous structures. 
Dr. W. Budd recommends the use of the microscope for the same pur- 
pose : — " If the characteristic cells were found on the cut surface of the 
portion removed, it would be morally certain that others have been left 
behind, and that the extirpation is incomplete, although, on the other 
hand, the absence of these cells would be by no means so sure a gua- 
rantee of their entire removal. Such an examination would, however, 
always be a matter of great interest to the surgeon."* The best security 
would lie in the operation being performed before the constitution has 
been, in any degree, impaired by the disease; and particularly, before 
any neighboring parts, especially lymphatic glands, have shown any 
indications of disease. The best chance will, therefore, be afforded in 
cases in which the growth is most chronic and inactive, and of the 
smallest extent, as in scirrhus of the lip, skin or breast. If any cancer- 
ous texture or germs are left behind, the operation is likely to do harm 
instead of good, by bringing them into activity, and developing the acute 
form of the disease. Cases have occurred, in which a cancerous breast 
has been completely removed by a spontaneous sloughing; but such an 
event is extremely rare. Cauterization is less advisable than excision, 
because less manageable. 

589. The second indication, to retard the development of the malig- 
nant growth, is chiefly to be attempted by means which diminish the 



* Lancet, May, 1842. 



332 



STRUCTURAL DISEASES. 



circulation through the diseased part. Repeated local bleedings have 
been found useful, partly, perhaps, in this way, but more by relieving 
the inflammation excited by the growth. The best means of staying the 
growth of malignant disease is by pressure, which has long had many 
advocates. Such a kind and degree of pressure as will reduce the cir- 
culation through the part to the lowest degree compatible with its life, 
will pretty surely arrest the increase of the morbid growth, by depriving 
it of its nutriment. But, for the utility of this measure, it is equally 
necessary that the disease shall not have extended to other parts besides 
those to which the pressure is applied, otherwise, in those parts which 
are commonly internal, the growth will proceed with an increased rapid- 
ity, proportioned to its suspension by the pressure on the outward part. 
The best means of applying pressure are those contrived by Dr. Arnott, 
especially the slack air-cushion under a compress. It is very doubtful 
that we possess any means of influencing malignant growths through the 
constitution. Various medicines have enjoyed an ephemeral repute for 
their efficacy in cancer. Of these, conium has been one of the most 
favorite. Dr. A. T. Thomson considers the iodide of arsenic to possess 
some power in controlling the increase of cancer. But it is doubtful 
that any of these remedies do more than soothe irritation, and restrain 
common inflammation and its results, with which malignant growths are 
generally complicated. 

Dr. Bennett does not coincide in opinion that cancer is necessarily 
fatal, because it is not easy to understand why nature should never cause 
the degeneration and disappearance of this one particular growth alone, 
whilst every other tissue and form of cell-life, was occasionally abortive. 
Cruveilhier, Trousseau, Hodgkin, and others, have frequently traced the 
conversion of scirrhus into ossiform matter, in the lower animals and in 
man. Dr. Bennett has seen this transformation in five cases, and he 
considers that they offer conclusive evidence that cancer is capable of 
undergoing the calcareous transformation. 44 It has been stated that 
cancer sometimes becomes transformed into fibrous or fatty tissue, and 
thus produces cicatrices in organs. It is very difficult to prove such a 
statement, because if there be no cancerous cells in a fibrous tissue, it is 
contended that it is not malignant, and never has been. On the other 
hand, if cancer-cells be present, it is clear that we have no evidence of 
degeneration. There can be no doubt that many organs and tumors are 
considered cancerous, which are only fibrous. Dr. Bennett has examined 
many so-called cases of scirrhus of the pylorus, which were only hyper- 
trophy of the muscular and fibrous tissue of the part. He alludes to a 
case of Dr. Alison's he had examined, in which the coats of the stomach 
throughout varied in thickness from an inch to an inch and a half. The 
viscus was thought by all who saw it to be cancerous, and yet he showed 
it to consist of nothing but fibrous tissue and fusiform cells. He had 
also proved many tumors supposed to be cancerous to be only fibrous. 
Professor Bochdalek, of Prague, formerly pathologist to the hospital there, 
and now professor of anatomy in the university, published a memoir in 
1845, 4 On the Healing Process of Cancer in the Liver. .' He describes 
the cancer in this organ as breaking down into a cream-like matter, the 
fluid parts being absorbed, and the whole shrinking together, forming a 



MORBID GROWTHS, MALIGNANT- 



' TREATMENT. 



333 



puckering on the surface, often corresponding to a fibrous mass or a 
fatty material, in which collapsed cancer-cells may yet be detected. In 
some livers he has seen these cicatrices in all stages of formation, cancer 
in some places, and perfect cicatrices in others. In Prague, he tells us 
there are between 400 and 500 bodies examined annually. Among 
these, cancer of the liver occurs about 16 or 17 times, and among these, 
proofs of healing may be observed between 6 and 7. (Oesterreichische 
Wochenschrift, 26th April, 1845.) Dr. Bennett has frequently seen 
these appearances in the liver, but he had never been able to satisfy 
himself that they were proofs of cured cancer. There are strong proba- 
bilities in its favor, however. Tubercular masses are rare in the liver 
of adults ; and such lesions must depend either upon cancer or upon 
chronic abscesses. 

"Dr. Bennett considers that, taking every statement into consideration, 
it was by no means improbable that cancer might occasionally degenerate 
into a fibrous mass, although we still require positive proof of it. At all 
events, they have convinced him of the necessity of making further re- 
searches on this subject. The same difficulties exist with respect to the 
supposed degeneration of cancer into fat. Nothing is more common than 
to find associated with cancer a yellowish friable matter, more or less 
abundant, resembling cream in color or consistence, or presenting a 
bright gamboge yellow tint. This, on examination, is found to consist 
of numerous granules, which disappear on the addition of ether, and 
refract light like globules of oil. Whether these granules are element- 
ary nuclei and cells, or whether they are the result of the disintegration 
of cells previously formed, is unknown."] 

590. The third indication, 1o counteract the effect of morbid growths, 
is more commonly the object of treatment ; but the means of fulfilling 
it fail more and more as the disease advances. The use of narcotics of 
every description,* general and local, to soothe the pain and irritation, 
and of occasional local antiphlogistic measures to remove inflammation 
and congestion, is commonly admitted in palliation of malignant dis- 
ease ; but the importance of tonics and nutritive diet to counteract the 
increasing cachexy and emaciation, is not so generally regarded. Yet 
these have appeared to me to have considerable efficacy in supporting the 
constitution, and supplying it with strength against the enemy that is prey- 
ing on its vitals. Preparations of iron, when borne, are the best tonics. — 
The remarkable absence of fat, in the textures wasted by prolonged can- 
cerous disease, suggests the possible utility of cod-liver oil as a nutrient 
article. 

* In this, and otber painful complaints, the acquisition of an effectual and harmless ano- 
dyne agent, is an inestimable boon to suffering humanity; and the discovery, by Professor 
Simpson, of the powerful anaesthetic influence of Chloroform, or terchloride of Formyle, 
promises to supply a. most valuable addition to our materia medica. Hitherto it has been 
used only (by inhalation of its vapor) to induce insensibility during painful operations, in 
the same manner as sulphuric ether (§ 128); but we may reasonably expect that an agent 
which, by its full influences, can destroy the most acute pains, may, by a moderate and more 
continued administration, permanently mitigate more constant sufferings. Probably, we may 
hereafter find this remedy available in the form of an anodyne smelling bolile. 



334 



STRUCTURAL DISEASES. 



SECTION IX. 

DISORDERS OF MECHANISM. 

591. Many structural diseases arise from changes in the mechanism of 
organs, which are not precisely implied in any of the preceding ele- 
ments. It is quite needless to enter into a detail of these alterations of 
mechanism ; but to complete our key to the elements of disease it will 
suffice to cite a few examples. 

Hollow organs are liable to dilatation from an undue accumulation of 
matter within them. Thus the heart, arteries, and veins, the air-cells 
of the lungs, portions of the intestinal tube, the bladder, &c, become 
distended when there is an obstruction to the passage of their respective 
contents, or when the expulsive power by which they are contracted is 
weakened; and such distention, if long continued or frequently repeated, 
becomes a permanent dilatation. 

Parts may become overstretched and relaxed by a loss of natural cohe- 
sion or elasticity; thus, ligaments, tendons, and fascia?, become relaxed 
and ineffectual in binding together or connecting the parts to which they 
are attached. 

592. Contraction is the opposite of dilatation. It may constitute 
stricture, and lead to the partial or total obstruction of parts of the canals 
of the intestines, urinary and respiratory apparatus, vascular systems, 
&c. The influence of contraction of the texture of organs and of serous 
membrane, we have several times had occasion to notice as the results 
of disease. 

593. Parts may be ruptured or lacerated, either from previous disease 
or from violence, and structural disease is the result. Thus, hollow 
organs, the heart or arteries, the stomach, the gall bladder, the urinary 
bladder, have been ruptured w T ith speedily fatal results. Rupture of the 
valves of the heart, of portions of blood-vessels, of air-cells, &c, injures 
the mechanism of these parts, and forms an element of structural disease. 

■594. Displacements and compressions of organs are frequently the 
effect of tumors or effusions, as in the case of the tumor of ascites, or 
ovarian dropsy, or an enlarged liver, pushing up the heart and lungs, 
and variously compressing and displacing the abdominal viscera ; of an 
enlarged heart or aneurism displacing and compressing the lungs and 
air-tubes; effusions in a pleural sac, compressing the lung of that side, 
and displacing the heart, mediastinum, diaphragm, liver, and the walls 
of the chest. 

595. Contortion of rigid parts is exemplified in rickets, mollities ossium, 
and rheumatic nodosities of the joints. Curvature of the spine, besides 
shortening the length of the trunk, disorders also the mechanism of respi- 
ration, by changing the position of the ribs; and when the distortion is 
great, the function of the heart and great arteries, and of the abdominal 
viscera, may likewise be affected by it. 



335 



CHAPTER V. 

THE CLASSIFICATION, SYMPTOMS, AND DISTINCTION OF DISEASES, 



SECTION I. 

NOSOLOGY. 

596. Having considered the causes of disease, their mode of operation? 
the resulting effects on function and structure in the ultimate and proxi- 
mate elements of disease, and the remedial influences which can be 
brought to remove or counteract these elements; we have next to notice 
the manner in which these elements of disease affect the several parts 
and functions of the body, the symptoms which they induce, and the 
combination or forms which they present, as special diseases. In order 
thus to allot together in distinct divisions the wide domain of disease that 
has been displayed by general pathology, it is necessary to define special 
diseases — that is, to designate their peculiarities of situation, kind, and 
phenomena, by short descriptions, and to group and subdivide them in 
classes, orders, genera, and species. This classification and definition 
of diseases is usually implied by the word Nosology. 

597. Diseases may be classed in different ways. The first method 
attempted was a classification according to their most prominent pheno- 
mena or symptoms. Of this kind was the system of Sauvage, who 
divided diseases into ten classes: — vitia, fibres, phlegmasia, spasmi, an- 
helationes, debilitates, dolores, vesania, fluxus, cachexia. The classifica- 
tions of Linnaeus, Vogel, and Sagar, were also of this kind, which may 
be termed artificial; and Cullen's division was a strained simplification 
of the same description of arrangement, condensing all diseases into the 
four classes — -pyrexia, neuroses, cachexia, and locales. 

The chief objection to this, which may be called symptomatic nosology, 
is, that it regards symptoms as the essence of diseases, whereas many 
symptoms are not essential, and those that more constantly occur are 
extremely variable, both in their kind and severity, and by no means 
uniformly correspond with the nature or with the amount of the real 
change of function and structure present. Hence, too, similar symptoms, 
from the most diverse causes, are classed together, although they may 
require quite opposite plans of treatment; whilst diseases that are really 
kindred in their nature, are widely separated, because they differ in their 
symptoms. The artificial method of classification is admissible only as 



336 



NOSOLOGY. 



a provisional means of arranging subjects in a conventional way, until 
the true nature of these subjects is investigated; when this is done, or 
even as it advances, the artificial method should give place to the natural 
one, which is not a mere glossary of names, (or symptoms,) but in itself 
expresses the most important points of knowledge of the nature of the 
subject. 

598. The true foundation of a natural classification of diseases is in a 
correct pathology, or knowledge of the intimate nature of diseases; but 
the subdivisions are conveniently determined by the chief seat of the dis- 
ease, or by other of its more prominent characters. The classification 
of Pinel approaches to this standard, although it is necessarily imperfect 
from the infant state of pathology at his period. He divided diseases into 
five classes :— -fevers, inflammations, hemorrhages, neuroses, and organic 
affections. 

Pathology may be applied to the classification of diseases in two modes. 
In one, it is the first step in the arrangement, all diseases being distri- 
buted in classes expressive of the several pathological elements affecting 
the systems defined by general anatomy. Thus, according to the groups 
of pathological elements which we have reviewed, the classes might be 
— diseases of the muscular system, those of the nervous system, of the 
secernent system, of the blood, of the vascular system, and of nutrition. 
The subdivision of these classes into orders would be determined by the 
individual pathological elements: thus, diseases of the muscular system 
would be divided into those of irritability and those of tonicity, with the 
generic subdivision according to excess, defect, or perversion ; and lastly, 
the specific distinctions would be made according to the organ or locality 
affected. This arrangement is not suitable for clinical or practical pur- 
poses, because diseases are generally too compound to admit of being 
classified according to their elements: they commonly comprise several 
pathological elements, and the proportions of these elements vary with 
the progress of the case. 

599. The other mode of using pathology in nosology, is by making 
it subservient to establish those divisions or subdivisions in which the 
character of its elements affords an obvious and natural mean of distinc- 
tion, which may be useful in the diagnosis and treatment of disease, 
whilst the remaining divisions are derived from the situation or other 
circumstances of the disease. Thus, diseases may be classed according 
to their chief locality, the organ or set of organs which they affect. Thus, 
as classes of disease, we may have, diseases of the organs of respiration ; 
diseases of the organs of circulation ; of the apparatus of alimentation ; 
of that of urinary excretion and of generation ; of the nervous system ; of 
the organs of locomotion ; of the skin; of the blood; and lastly, general 
diseases, have no defined seat. The division of these classes into orders is 
founded on pathology: thus, each class comprehends/knc^ofta/ diseases, 
subdivided into diseases of irritability, tonicity, sensibility, &c, and secre- 
tion; and inflammatory and congestive diseases ; and diseases of nutrition 
(structural). A further division into genera and species is made accord- 
ing to the anatomy of the parts: thus, of the class, diseases of the organs 
of respiration ; order, functional disorders ; genus, irritability ; the species 
would be spasm and paralysis of the larynx of the bronchi, &c. But in 



CLASSIFICATION OF DISEASES. 



337 



general diseases, the subdivisions must be altogether pathological, or 
founded on causes or symptoms: thus, fevers are distinguished into 
inflammatory, eruptive, adynamic, or contagious, and malarious or inter- 
mittent, and continued, as each of these modes of distinction becomes 
most available. 

This last classification, although it may be less pure and methodical 
than others, is the most useful in practice, because it most closely follows 
nature, and, setting aside more minute and difficult distinctions, it leads 
to the seat and nature of the disease, and renders available those general 
principles in pathology and therapeutics which form the foundation of 
rational medicine. A chief recommendation of this kind of nosology, 
or arrangement of individual diseases, is, that whilst it includes all dis- 
eases hitherto distinguished, it points out others which may and do occur, 
but for want of distinct pathological views and names, have been con- 
founded w T ith those more prominently defined. 

600. The definitions by which individual diseases are designated, may 
refer either to the pathological nature of the disease, or to its charac- 
teristic symptoms, or to both, and in some instances, the causes or results 
of the disease form a characteristic part of its history. It should be 
remembered that the great purpose of nosology is to arrange and define 
diseases in such a manner that their true nature, with the chief points of 
affinity and difference between each other, may be expressed by the 
arrangement and definition ; and whether these points of affinity or dif- 
ference are most manifest in the causes, nature, or symptoms of the dis- 
eases, the arrangement and definition should duly regard them. Thus, 
besides its chief peculiar symptoms, the definition of a distinctly infec- 
tious disease, as scarlatina, should express its infectious character; that 
of a disease indubitably caused by marsh miasmata, as ague, should 
imply this fact; wmilst, both being classed as general diseases, and in 
the order fevers, the one of the genus eruptive, the other of the genus 
intermittent, much of the nature of the diseases, as well as of their dis- 
tinguishing characters, will be set forth by this nosological arrangement. 
The further that our knowledge of pathology is advanced, the more con- 
siderable a part will it form in our nosological systems ; but in the mean- 
time it is better to render our classification and definitions as useful as 
possible, by deriving them from all the most available sources of infor- 
mation, than to keep them imperfect and inapplicable until science is 
sufficiently advanced to supply us with a system that is quite pure. 

As we do not enter upon special pathology, or the history of individual 
diseases, it is unnecessary to proceed into details of nosology. The 
foregoing remarks are intended merely to explain the objects of noso- 
logy, and to introduce the two associated subjects, semeiology and diag- 
nosis. 



22 



338 



SEMEIOLOGY. 



SECTION II. 

SEMEIOLOGY AND DIAGNOSIS. 

601. Semeiology treats of signs,* and in medicine, of the signs of dis- 
ease. The word symptom is commonly used in the same sense as sign; 
but, as its etymology implies,! it is a more vague expression, signifying 
coincidence or co-occurrence rather than a direct or constant connection. 
It has been attempted by some writers (particularly French), to restrict 
the word symptom to the phenomena manifested by present disease only; 
but this is contrary to the usual custom by which we speak of precursory 
and consecutive symptoms, symptoms of health, &c. Again, some have 
confined the term symptom to the phenomena depending on vital pro- 
perties, whilst those phenomena of disease which are more directly 
physical, they call signs. This was the sense in w T hich Laennec used 
these words, and others have followed his example. Although this ac- 
ceptation of the words is not in strict accordance with former usage, or 
with their etymology, yet it would be convenient for conventional use ; 
and to render it more precise, it will be well to prefix the epithets vital 
and physical, as first suggested by Bayle, and partially adopted by 
Laennec. 

Let us, then, understand the word sign of disease generally to imply 
anything by which the presence of disease may be made known. A 
symptom is any phenomenon which becomes obvious in the course of 
disease : it may thus often prove to be a sign ; but many symptoms are 
of such uncertain connection with a particular disease, that they cannot 
be said to make known the presence of a disease, and therefore they 
cannot be called signs. The more specific designation of physical signs 
and vital symptoms will succeed better in attaching a distinct meaning 
to the different phenomena of disease; and by stating briefly the grounds 
of this distinction and the proper application of the terms, we may be 
able to point out the respective value of each class of phenomena to 
which they are properly applied. 

602. Physical signs are those physical properties of the body, or of a 
part of it, which are perceptible to any of the senses of the observer. 
Thus, the form, size, color, firmness or softness, weight, heat, and odor 
of the whole body, may be said to give physical signs or evidence of its 
condition, whether in health or in disease. So, also, the form, size, color, 
resistance, position, temperature, smell, and acoustic properties of a part 
of the body, afford physical signs of its condition, whether in health or 
in disease. Thus, the appearance of an external disease, the feeling of 
a solid tumor, or of the fluctuation of liquid in the abdomen, listening 
to sounds produced by or in diseased internal parts, furnish us with phy- 
sical signs of the presence of disease. 

* " Sign, that by which anything is known." — Johnson's Dictionary, 
f IvfATrvufxa, from a-vv, with, and tmttq or tttow, to fall. 



SIGNS OF HEALTH AND DISEASE. 



339 



The difference between the signs of health and the signs of disease is 
determined by our knowledge of what is usual in health; and this know- 
ledge may be derived (1) from general observation or experience of 
healthy standards, or (2) from anatomical and physiological knowledge 
of what the phenomena of health ought, to be; or (3) from a particular 
knowledge of the standard of health in any individual case. 

All of these healthy standards of comparison are available: the first is 
less exact than the other two; but it is often available for obvious dis- 
ease. Thus, a jaundiced hue of the body, extreme pallor, or great emaci- 
ation, affords to the common observer physical signs of disease w T hich 
cannot be mistaken. But slighter degrees of the same signs may become 
manifest only to those who, by previous acquaintance, know more exactly 
the standard of health in the individual, and can distinguish a change 
in color or in flesh from that standard. Again, in local disease: a large 
tumor or swelling in a part is a sign of disease obvious to every one; 
but a smaller or more deep-seated tumor may be discovered by those only 
who have an accurate knowledge of the healthy anatomy of the part, or 
by those who, by previous observation, have made themselves familiar 
with the shape and feel of the part in health. 

603. Another standard available to distinguish the physical signs of 
disease from those of health is a comparison of parts that are naturally 
symmetrical. Thus, a slight swelling in one limb may be readily dis- 
covered by comparing it with the corresponding part of the opposite 
limb. A projection or contraction of one side of the chest may escape 
observation until the two sides are compared by inspection or by measure- 
ment, which will detect the difference between parts that are naturally 
alike. This standard of symmetrical comparison is applicable, not only 
to all external parts and organs of animal life, but also to some internal 
parts, which, although not strictly symmetrical, are so far equally dis- 
tributed on the two sides as to give symmetrical properties to the exterior. 
Thus, the lungs, in health, fall so equally on both sides of the chest, 
that they give corresponding motion and acoustic properties to both ; 
and percussion or respiration yields similar signs on both sides. So, 
when disease affects one side, it changes its physical signs, and their 
difference becomes obvious by comparison with the signs of the healthy- 
side. A certain degree of uniformity also results from the position of 
the viscera in the abdomen, so that (making allowance for the greater 
bulk of the liver on the right side), any considerable difference in the 
shape or resistance of the two sides may be interpreted to be a sign of 
disease. 

604. For organs which are not symmetrically placed, previous know- 
ledge of their natural structure, position, and physical properties, is 
necessary. Thus, we cannot know the physical signs of diseases of the 
heart and liver, without having a healthy standard to compare them with. 
This standard is soon supplied by the observation of the signs in health, 
and our knowledge of it may be much assisted by a familiar acquaint- 
ance with anatomy and physiology, which teach the healthy condition 
and functions. Thus, anatomy teaches us that the heart lies behind the 
lower half of the sternum and the adjoining parts of the cartilages of 
the left ribs from the third to the sixth ; and physiology makes us a^ 



340 



SEMEIOLOGY. 



quainted with its regular double sound heard in this region ; these furnish 
a healthy standard, and when we compare it with a case in which the 
impulse of the heart is felt to beat over a much wider space, and the 
sounds are irregular, and masked by grating or blowing murmurs, we at 
once discern these phenomena to be signs of disease. Again, anatomy 
informs us that the liver in a healthy adult extends little, if at all, below 
the margins of the ribs on the right side ; and the knowledge of this fact 
points out as a sign of disease such dullness on percussion and resist- 
ance to pressure below these ribs as arise from the liver reaching much 
below its usual situation. The knowledge of the healthy mechanism 
and functions of the apparatus of respiration, circulation, digestion and 
excretion, is in many respects necessary to enable us to distinguish the 
signs of disease from those of health : it will guide us to refer the signs 
to their true causes ; and it may often suggest the particular signs which 
may be expected to arise from a particular lesion. 

605. Physical signs are phenomena taking place in the body, in ac- 
cordance with physical laws. It is, therefore, obvious, that a knowledge 
of these laws, as well as of the mechanism of the body, will assist us 
to interpret these phenomena; to explain of what they are signs, how 
they are caused, the variations which they may present, and the best 
mode of appreciating them. Thus an aneurism of the arch of the aorta 
may be chiefly detected and studied through the physical signs which it 
produces. It forms a tumor under or near the top of the sternum, pul- 
sating in a distinct manner, and with a peculiar sound ; this tumor may 
press on the air-tubes in such a way as to alter their shape, and by par- 
tially obstructing the passage of the air through them, may also change 
the sound of breathing in a particular way: by compressing the veins, 
it may also throw their current into unusual sonorous vibration; or by 
a more complete obstruction, it may cause the veins to swell in a re- 
markable degree above the tumor: by its enlargement, the aneurism 
encroaches on the lungs, the walls of the chest, the muscles, nerves, 
bones, ligaments, &c, in such a way as to alter their physical proper- 
ties and positions, and thus to produce various physical signs. Now, all 
these physical signs are phenomena produced in the altered mechanism, 
according to certain laws; and it is plain that a knowledge of these 
law T s most greatly assists us to understand the signs, and to trace them to 
their true causes. Nay, even the aneurismal tumor itself, in its produc- 
tion, increase, and intrinsic signs, can be rightly understood only through 
a knowledge of hydraulics and dynamics, in connection with the struc- 
ture of the heart and arteries in health and disease. 

606. Vital symptoms are those phenomena w 7 hich depend on vital 
properties of a part or parts of the body. Thus irritability, tonicity, 
sensibility, excito-motion, secretion, and the more complex functions re- 
sulting from combinations of these elementary vital properties (§ 104), 
in a natural state, produce the symptoms of health ; in an altered state, 
constitute the symptoms of disease. Hence vital symptoms have also 
been called functional symptoms, and physiological ; but both these terms 
are objectionable, because both function and physiology relate likewise 
to physical properties, and would, therefore, include physical signs. 

Vital symptoms are often less confined to a part than physical signs; 



PHYSICAL SIGNS AND VITAL SYMPTOMS. 



341 



because vital properties of the whole system are in mutual connection ; 
thus the irritability of the heart spreads its influence throughout the vas- 
cular system ; the sensibility of one part affects the nervous centres, and 
may produce sympathetic symptoms in other parts (§156); disordered 
secretion has effects on other parts (§§ 162 — 7, &c); so that vital symp- 
toms are often generally distributed throughout the body. For this rea- 
son, they have been sometimes called general symptoms, to distinguish 
them from physical signs, which are chiefly local; but this appellation 
is not exact, inasmuch as vital symptoms are sometimes entirely local: 
as in the case of pain, spasm, &c. ; and we have already mentioned, that 
physical signs are sometimes quite general throughout the body, as those 
of the yellowness of the whole surface in jaundice, the swelling of the 
body in dropsy, &c. 

Vital symptoms are sometimes called rational, because (I presume.) 
their connection with their cause is rather a matter of inference than of 
direct observation ; but this is the most absurd term of all ; for observa- 
tion is necessary to teach us the value as much of symptoms as of phy- 
sical signs; and physical signs are of little use without a proper exercise 
of reason upon them. 

607. Vital symptoms may be exemplified in pain, uneasiness, altered 
and impaired sensations, which arise respectively from exalted, perverted, 
or defective sensibility (§§ 125 — 136) in spasm and paralysis, which 
proceed from excessive or defective contractility (§§ 110 — 118), or ex- 
cito-motory power (§§ 139 — 154) ; in cough, w T hich is caused by irritation, 
or undue excitability of the excito-motory nerves of the air-passages, and 
muscles of expiration ; in vomiting, which depends on irritation or un- 
due excitability of the stomach, and the excito-motory nerves sympa- 
thetically allied with it; in dyspnoea, which arises from a feeling of w 7 ant 
of breath (§ 234); in fever, which comprises an accelerated pulse, hot 
skin, diminished secretions, &c. (§ 437). 

Symptoms may further be found in the state of the different bodily 
functions in which vital properties are concerned. Thus, the state of 
the pulse is an important source of symptoms ; a frequent or a slow pulse 
indicates an increased or deficient excitement or irritability of the heart 
(§§ 113, 117); a strong or weak pulse implies an increased or diminished 
strength of the heart's contractions (§§ 112, 116). A hard or sharp 
pulse is, in part, dependent on an increased tonicity of the arteries 
(§ 121); whilst a soft, compressible, or liquid pulse, depends on a dimi- 
nution of this property (§ 123). Irregularity in the rhythm of the pulse 
arises from an alteration in the vital property of irritability in the heart, 
commonly connected with loss of strength. These various conditions 
of the pulse are sometimes the result of various diseases directly affecting 
the vital properties of the heart and arteries themselves ; but more com* 
monly, they are induced by diseases of other parts sympathetically, or 
through the blood influencing these organs, as in inflammatory fever 
(§ 437). Thus, in diseases of the heart and arteries, the pulse has more 
of the character of a physical sign; whilst in other disorders, it is rather 
a vital symptom, depending on further vital properties. 

The state of the skin is another source of symptoms, chiefly connected 
with the- vital- proper-ties of- the superficial vessels and secernent appara- 



342 



SEMEIOLOGY. 



tus, and of the general circulation. Thus, the heat and dryness of the 
skin in fever, arise from accelerated circulation with diminished perspira- 
tion. When the skin is cold, the circulation is weak; when warm, it is 
active ; and the occasional occurrence of perspiration in both these con- 
ditions, shows that another vital property, that of secretion, is concerned 
in causing the symptoms, dryness and moisture of the skin. The signs 
furnished by the skin are physical, so far as regards the condition of the 
skin itself ; but they are vital symptoms in relation to the state of the 
circulation, of distant organs, or of the system at large. 

Many important symptoms may be derived from the appearances of 
the tongue. These appearances, when arising from primary disease in 
the tongue itself, may be considered as physical signs of its condition. 
Thus, when the tongue is inflamed, it is first red and swollen, and after- 
wards becomes covered with a film or fur, which, separating in patches, 
leaves the surface red, and smoother than before. But in a great many 
diseases, the tongue becomes red, swollen, furred, or brown and dry, 
from causes acting through the system ; and these secondary affections 
of the tongue constitute symptoms of these diseases. The connection 
between febrile and other general diseases, and the appearances which 
they produce in the .tongue, is not well understood; but it probably de- 
pends on changes in the secretion of the mucous membrane covering the 
tongue and adjoining parts. 

The alvine excretions furnish symptoms of great importance in various 
diseases. When excessive in quantity, liquidity, and frequency, they 
constitute diarrhoea, which may be primary — that is, a disease in itself 
(§ 374); or secondary, and, therefore, a symptom of disease, as in cho- 
lera and mucous enteritis. As a -symptom, it presents further varieties 
in its character, whether feculent, bilious, mucous, watery, &c. ; and 
these varieties indicating respectively accumulation of feces, or exces- 
sive secretion of bile, or mucus, or watery fluid, in the intestines. The 
opposite condition, that of costiveness, is also a disease itself, and an 
important symptom in many diseases, indicating defective peristaltic 
action, defective secretions, or both, in the intestinal tube. The quality 
of the evacuation supplies symptoms in regard to color, shape, odor, 
&c, which often lead to a knowledge of the nature of disorder in the 
alimentary canal or in the system. Thus clay-colored feces indicate 
defective secretion from the liver; those very dark in color may denote 
the presence of diseased bile, or altered blood ; vermicular motions may 
indicate stricture, or contraction of the intestine, and so forth. 

The urinary excretion is a valuable source of symptoms, not only of 
diseases of the parts connected with it, but of disorders of other organs, 
and of the whole system. Being the chief emunctory through which 
foreign, effete, and superfluous matters are eliminated from the blood 
(§ 254), it is continually exhibiting changes in quantity and quality, in 
color and specific gravity, in its sediments, and in the effect on it of 
different chemical reagents. All these changes furnish symptoms of dis- 
ease, several of which have been already noticed in connection with 
various pathological elements (§§ 167, 176, 249,254,255, 257, 260, 
309, 384, 385, 448, &c). 

608. The foregoing examples of sources of symptoms are given 



PHYSICAL SIGNS AND VITAL SYMPTOMS. 



343 



merely to illustrate where and how symptoms are to be sought for ; to 
complete the list, it would be necessary to notice every function of every 
part of the body, and the symptoms which they furnish, which would fill 
a considerable volume. 

As a knowledge of the mechanism of organs, in health and in disease, 
and of the physical laws which operate in them, is the best aid to the 
study of physical signs, so an accurate acquaintance with the structure 
and functions of the healthy and diseased body, and with the vital laws 
which influence them, is the best guide to the knowledge and explana- 
tion of vital symptoms. These symptoms are often obscure and unin- 
telligible, because physiology and pathology are imperfect ; but, in pro- 
portion as these sciences are advanced, their application to semeiology 
and diagnosis will be more complete. In the mean time, much of our 
knowledge of symptoms rests chiefly on mere experience ; and until the 
results of experience can be arranged in a more scientific manner, they 
may be parceled numerically, in order to approach their laws by empi- 
rical means. But to render this statistical or numerical method of study- 
ing symptoms at all safe, it is necessary that the number of observa- 
tions should be very large, that they should be applied to similar cases, 
and that the majorities which establish the rule, should very greatly pre- 
ponderate over the exceptions. 

609. Physical signs and vital symptoms respectively have their value 
in making known the nature and extent of disease. Physical signs are 
more certain, because they appeal more directly from the seat of disease 
to the senses ; depending on simpler and more constant causes, physical 
properties, they are more constant, and less subject to variation than 
vital symptoms, which result from more complex, and therefore more 
variable, vital properties. Thus of the signs of inflammation, the red- 
ness, heat and swelling are physical signs, and more certainly prove 
the existence of inflammation than does pain, which is a symptom de- 
pending on the vital property, sensibility, and which may be present 
where inflammation does not exist (§ 136), and may fail to occur when 
inflammation is present (§ 433). The physical signs of a structural dis- 
ease in the lungs or heart, are better evidence of its existence, and of its 
nature, than cough, dyspnoea, pain, palpitation, &c. ; because we know 
that these symptoms may arise from merely nervous, or other causes, 
without the presence of any alteration of structure. Yet vital symptoms, 
although less sure and constant than physical signs, are often more deli- 
cate, being present before physical changes become appreciable ; and 
when they coexist with visible signs, they indicate the nature and 
amount of disorder of the vital properties of the part, and of the whole 
system. Thus feelings of chilliness and discomfort, which usher in the 
fever accompanying tonsillitis, are sometimes present before the throat 
exhibits the physical signs of inflammation. A slight cough is often 
present in the early stage of phthisis, before the physical signs of tuber- 
cles can be distinguished. Crepitation heard in the posterior regions of 
the chest is a physical sign of engorgement of the lung, with liquid in 
the minute tubes; but we must refer to the vital symptoms to determine 
whether the engorgement is inflammatory, or only congestive. The 
physical signs of consolidation of the lung, and of valvular disease of the 
heart, are very distinct; but, in order to determine whether these affec- 



344 



SEMEIOLOGY. 



tions have arisen from present or recent inflammation, or are the results 
of old disease, it is necessary to consult the vital symptoms; and this 
determination is of great importance to the prognosis and treatment. 

In short, it is obvious that both classes of signs ought to be carefully 
taken into account ; and the more fully the physical and vital properties 
which constitute them are understood, the more available will signs and 
symptoms be, to instruct us as to the nature and treatment of disease. 

610. Besides into physical and vital, various divisions of symptoms 
have been made; but they are of little real utility, and it is unnecessary 
to do more than enumerate them. Symptoms are local, or general, or 
constitutional, according to whether they are confined to the diseased 
part, or affect more or less the whole system. Symptoms are idiopathic, 
when directly proceeding from a primary disease ; they are sympathetic, 
or secondary, when arising from secondary disorders, or those produced 
by the primary disease. Premonitory or precursory symptoms are those 
which precede the full development of disease, and commonly result 
from the first operation of its cause ; hence they are called symptomata 
causae. Commemorative symptoms are those developed in the previous 
history of the disease. Anamnestic are those which relate to the previous 
state of health. Signs have been divided into objective, those which pre- 
sent themselves to the scrutiny of the practitioner; and the subjective, 
those described by the patient himself. The objective have been further 
divided into the active or dynamical, those that require some action, mo- 
tion, or manipulation, to discover them; and the passive or statical, those 
which are obvious without such action. Symptoms are designated by 
the epithets diagnostic, prognostic, and therapeutic, when they are specially 
applicable respectively to the distinction, the determination of the event, 
and the suggestion of the treatment of disease. Symptoms are positive, 
when they consist of phenomena actually present ; negative, when they 
consist in the absence of phenomena. Of diagnostic symptoms, those 
are called pathognomonic or pathognostic, which are peculiar to one dis- 
ease. A single symptom or sign is rarely, if ever, pathognomonic ; but 
two or three taken together often are so. 

[Some of the more important general signs of disease will be now 
enumerated. In the study of semeiology, several methods have been pur- 
sued. The one most useful, and most generally practical, is, probably, 
that compounded of the topographical method, in which the symptoms 
presented by each portion of the body are treated of successively; — and 
the physiological method, which studies each apparatus of organs and 
functions, approximating those which offer most relation and analogy, thus 
grouping, in a natural way, the various symptoms which the case presents. 
Accordingly, after an exposition of the signs derived from the external 
exploration of the patient — commencing with the body as a whole, with 
reference to attitude, configuration, and volume, and then passing to the 
consideration of the signs furnished by each region of the body respect- 
ively — we shall detail the symptoms and signs supplied by each of the 
great functions — as the nervous, respiratory, circulatory, &c. (§ 615). 

I. The symptoms presented by the exterior of the body, are of the 
greatest importance. By a first glance at the general aspect of the pa- 



DECUBITUS. 



345 



tient — a coup rfceil d? ensemble — the experienced physician of quick per- 
ception and tact, derives most valuable information, and often recognizes 
the nature of the disease, and ascertains the actual condition of the 
patient. Many diseases, indeed, have their own special physiognomy, 
which is readily recognized by the initiated. "Medical physiognomy," 
it has been well observed, " is, in many diseases, a source of diagnosis 
which seldom fails the practitioner who is intimately versed in it; and 
we believe that much of that exquisite tact in the discrimination of dis- 
ease which distinguishes some practitioners, and which others can never 
attain, depends on the vivid perceptions of an eye and ear habitually 
familiar with the lineaments, the tone, and the gestures of disease."* 

The position and movements of the body and limbs, and the constitu- 
tional peculiarities and physiognomy of the patient, are of importance in 
a correct diagnosis. 

The attitude varies more or less in disease. There may be an unusual 
degree of languor, as in the invasion of most acute diseases, or in the 
course of chronic ones ; or the bearing may be unnaturally bold and 
assured, as in insanity or acute delirium. There are some diseases 
which may be at once recognized from the position of the patient ; as 
catalepsy, from general immobility; chorea, from irregular and per- 
petual movement ; hemiplegia, from distortion of the features, and 
altered position and impaired motion of the limbs; and tetanus, from the 
condition of the trunk. 

The signs furnished by decubitus or decumbence — the posture of lying 
— are often of value. In health, the position in sleep is on either side, 
perhaps oftener on the right, the body and limbs semiflexed, and the 
head bent towards the chest. A departure from healthy decumbence is 
noticeable in most diseases. When it is constantly dorsal, it is a token 
of extreme debility ; of loss of motion ; or of some affection in which 
movement is accompanied with severe pain. Hence we meet with it in 
all diseases attended with great prostration ; in cerebral apoplexy, and 
in organic diseases of the brain and spinal marrow ; in acute perito- 
nitis ; and in general articular rheumatism. The decumbence is prone in 
gastric, intestinal, hepatic and renal colic, though generally not lasting, 
the patient frequently changing his position. It is lateral in certain af- 
fections of the chest, as pleurisy or pneumonia, or rather in certain stages 
of those affections. No general rule can be given as to the position in 
bed of patients suffering under inflammation of the pleura or lung. It 
is very variable; sometimes on the affected, sometimes on the sound side; 
but, more frequently, if the effusion or hepatization be considerable, on 
the back. In double pleurisy or pneumonia, it is probably always dorsal. 
In pulmonary tuberculosis, where one lung only is affected, the patient 
lies by preference on the diseased side. 

The sitting posture is generally assumed in certain affections of the 
thoracic viscera, which interfere with respiration, and cause orthopnoea 
— diseases of the heart, and arch of the aorta, acute phthisis, pneumo- 
thorax, hydrothorax, emphysema of the lungs, nervous asthma, &c. In 
this position, the body is usually inclined forwards, with the elbows rest- 



* British and Foreign Medical Review. July, 1841, p. 108, 



346 



SEMEIOLOGY. 



ing on the knees ; or some firm object is grasped by the hands, to fix the 
shoulders, and allow the respiratory muscles to act to greater advantage. 
In some affections of the abdomen, in which the cavity of the chest is 
invaded, and respiration impeded, the patient is obliged to be propped up 
in bed, or maintain the sitting position. 

In laryngeal and tracheal disease, or where these organs are compressed 
by a tumor, the head is usually thrown back, whether the attitude be that 
of standing, sitting, or lying. 

Persistence in the same position is usually a symptom of organic dis- 
ease of the brain, or of idiocy. 

Restlessness, jactitation, or constant change of position, occurs at the 
invasion of acute inflammations, and the idiopathic fevers, and in many 
of the affections of children ; and frequently accompanies delirium and 
acute mania. 

The volume of the body may be augmented or diminished. A slight 
and transient increase of size occurs in the commencement of inflam- 
matory affections, and marked general tumidity of the body at the 
invasion of the exanthemata. An accumulation of fat is rarely a 
sign of disease, but may, when excessive, constitute a disease in 
itself — polysarcia. General enlargement of the body may proceed from 
anasarca, or dropsy of the cellular tissue, or from cellular emphysema, 
caused by a penetrating wound of the chest. Emphysema may be dis- 
tinguished from anasarca by its not pitting on pressure ; by its elastic 
feel, and by the sensation of crepitation which it gives. When the cel- 
lular infiltration is partial, it is termed cedema. (Edematous swelling 
may be more easily recognized when the disposition of the skin allows 
us to pinch it between the fingers. Incipient oedema may be often thus 
distinguished in patients confined to their beds, in the internal surface 
of the thighs (Ohomel). In those who are up, oedema first shows itself 
around the malleoli, particularly towards evening. 

Diminution in the size of the body is a frequent phenomenon in dis- 
ease. It may occur with great rapidity, and to a considerable degree, 
after excessive alvine discharges, as in serous diarrhoea, and Asiatic 
cholera. It is said to take place, in the same manner, after one or two 
paroxysms of malignant intermittent. It generally occurs more slowly, 
constituting emaciation. Emaciation is a much more frequent conse- 
quence of disease than obesity. It attends most chronic diseases; and 
is often among the first symptoms of phthisis. The emaciation of spe- 
cial parts of the body is observed in some maladies. In disease of the 
liver and spleen, the face and extremities first waste; in tubercular 
phthisis, the upper extremities and clavicular regions. 

II. The signs furnished by the head, face, and neck, present nume- 
rous points of value. 

The head is bent to one side in convulsions, hemiplegia, torticollis, 
dislocation of the cervical vertebrae, cervical glandular swellings, and 
large cicatrices of the neck, following burns. In vertebral malformation, 
it is bent forward. It is bent backwards in diseases accompanied with 
dyspnoea; as croup, laryngismus stridulus, suffocative catarrh, &c; 



THE PHYSIOGNOMY. 



347 



as well as in tetanus, and spinal meningitis of the cervical portion of 
the cord. The size of the cranium is increased in chronic hydroce- 
phalus, and hypertrophy of the brain. The hairy scalp becomes cedema- 
tous in erysipelas, with extreme sensibility on pressure. It is sometimes 
enormously swollen in small-pox. 

The physiognomy presents numerous shades of expression in the sick. 
It may appear sad, dejected, uneasy, terrified, indifferent or attentive ; 
sometimes smiling, at others menacing, or wandering, without there 
being any circumstance to account for these modifications of the features ; 
which, consequently, should be classed among morbid phenomena. 
(Chomel.) Among the changes of countenance noticeable in disease, 
are the following: The fades stupida, distinguished by the great dull- 
ness of expression, particularly of the eyes, the patient appearing as if in- 
toxicated. This is the physiognomy of a patient with typhoid fever. The 
fades vultuosa, characterized by fullness and redness of the face, pro- 
minence of the eyes, injection of the conjunctiva, distention of the eye- 
lids and lips. It is met with in cardiac hypertrophy, and in cerebral 
congestion. The pinched countenance presents the opposite conditions, 
the face being apparently diminished in size from contraction of the fea- 
tures, and of a pale or livid hue. It is seen in acute peritonitis, and in 
healthy persons who have been long exposed to severe cold. The fades 
hippocratica is thus described by Hippocrates: — The nose is sharp, the 
eyebrows knitted, the eyes hollow and sunken, the ears cold, contracted, 
and thin, and the lobes shriveled; the skin about the forehead is hard, 
tense, and dry; and the face pale, or of a greenish, livid, or leaden hue. 
It occurs in chronic disease immediately before death, and in acute dis- 
ease which has been unusually prolonged. 

Dr. Siebert distinguishes six groups of physiognomical rugse. The 
R. transversa, situate in the forehead, formed by the frontal muscle, 
express excessive pain arising externally. The R. oculo -front ales, ex- 
tending from the forehead vertically to the root of the nose, express dis- 
tress, anxiety, anguish, and severe internal pain. They also indicate in 
acute diseases an imperfect or false crisis, an impending efflorescence, 
and often a fatal termination. In severe headache, both the classes of 
rugae just mentioned are observed. When the former join the latter 
abruptly in a disease, paralysis is impending or commencing. The 
linea oculo-zygomatica (of Jadelot), extending from the inner angle of 
the eye somewhat below the cheek-bone, indicates in children a cerebral 
or nervous affection: in adults, disorder or abuse of the generative 
organs. The linea nasalis of Jadelot and De Salle (the Rhinal-linea 
orbicularis of K. H. Baumgartner) begins at the upper border of the ala 
nasi, and extends more or less curved to the outer margin of the orbicu- 
laris oris. It is strongly marked in phthisis and atrophy. The inferior 
portion (linea buccalis) indicates gastric disease; the upper portion (the 
proper linea nasalis), marks an affection of the upper part of the intestinal 
canal. Occurring conjointly with retraction of the cheek and with the 
L. oculo-zygomatica, the eyes being fixed and the complexion wan, it is 
a certain indication, according to Pieper, of worms. The L. labialis 
extends from the angle of the mouth, and is lost in the lower part of the 
face. In children, it generally marks a thoracic affection, which renders 



348 



SEMEIOLOGY. 



the respiration laborious or painful. The L. collateralis nasi passes 
downwards in a semicircular direction towards the chin, and externally 
to the linea nasalis, buccalis, and labialis. It generally indicates chronic 
and obstinate disease of the thoracic or abdominal viscera.* 

Many of the specific forms of disease have their specific physiognomy. 
Children of a scrofulous constitution have either a delicate velvety skin, 
brown complexion, dark hair, with dark and brilliant eyes, and long 
lashes, with the lineaments of the face finely drawn and expressive ; or, a 
fair complexion, thick and swollen nose, broad chin, irregular teeth, late 
developed, and early becoming yellow and carious, with inflammation of 
the Meibomian glands, scrofulous ophthalmia, intolerance of light, erup- 
tions on the head, nose, and lips, and enlarged cervical glands. 

(Edema of the face and eyelids is sometimes met with in anemia, but 
very frequently is symptomatic of albuminuria. 

Transient general redness, or flushing of the face, is common in wo- 
men suffering from menstrual irregularity, and at the critical period of 
life. The bright circumscribed redness of the malar regions, with pale- 
ness of the rest of the face, known as the "hectic flush," occurs in 
wasting chronic affections, and particularly in phthisis pulmonalis. 
When it is limited to one cheek, the corresponding lung has been 
thought to be the affected one. This certainly is by no means general; 
but Dr. Stille mentions a case observed by him. The same opinion 
has been entertained with regard to the livid red patches in the same 
region in acute pneumonia; but the researches of Grisolle do not coun- 
tenance it. 

Paleness of the face happens in the cold stage of fevers, and acute 
inflammations; in the hemorrhages; in chronic diseases, particularly 
Bright's disease; and in convalescence. The complexion of persons long 
deprived of a due amount of light, is unusually pale. The hue of the com- 
plexion of anemic patients is that of imperfectly bleached wax, or of a 
dingy white, with a shade of green. A general yellow tint of the face is 
characteristic of jaundice. Sometimes in slight hepatic derangement, 
the yellowness is limited to the labial commissures, and alse nasi. A 
citron tint is constant in cancerous affections; and a peculiar dingy light 
straw color hue is met with in the inhabitants of malarious districts. 
A bluish hue of the face, and skin generally, is indicative of impeded 
venous circulation ;" it is met with in asphyxia, from whatever cause*; in 
Asiatic cholera ; in typhus fever ; and particularly in cyanosis (§ 238), and 
hence is often called the cyanotic hue. It partially disappears on pres- 
sure to return slowly. A permanent and deeper discoloration, amounting 
to slate color, is met with in persons who have been long subjected to 
the internal administration of nitrate of silver. It is indelible. 

Perpetual motion of the eyelids is noticed in some cases of mania and 
idiocy. In adynamic fevers, they are sluggish and heavy. In photophobia, 
they resist any attempt to open them. They remain open when the 
portio dura has been injured, in consequence of paralysis of the orbicu- 
laris. When there is lesion of the third pair of nerves, the upper lid is 
paralyzed. Epiphora, or the flowing of the tears over the cheek, is caused 

* Technitt der Medicinischen Diagnostik. B. and F. Medical Review, vol. xx. 



FORM OF THE CHEST. 



349 



by obstruction of tbe lachrymal duct; — it occurs in the initial stage of 
ophthalmia, and in some neuralgic affections of the eye; and may be 
produced by the presence of a foreign body. 

The nostrils dilate forcibly and rapidly in difficult respiration. Itching 
of the nostrils in children, is commonly regarded as a sign of intestinal 
worms. 

III. The throat becomes enlarged in some anginose affections, in the first 
months of pregnancy, and at the approach of puberty in the female. The 
carotid arteries pulsate violently in acute mania, cerebral inflammation, 
hypertrophy of the heart with dilatation of the right ventricle, in anemia, 
and sometimes in typhoid fever. Habitual fullness of the jugular veins- 
occurs in connection with some impediment to the circulation. Pulsation 
of the veins of the neck, and particularly of the jugular — called the venous 
pulse — is caused, according to the researches of Dr. Beau, by contraction 
of the right auriculo-ventricular orifice — whilst by others it is attributed 
to patency of the tricuspid valves. Mr. Sibson has judiciously analyzed 
the influence of the heart's action, and of respiration on jugular pulsation.* 
The mere existence of such pulsation, he concludes, is anything but an 
indication of disease, either in the pulmonary valves or elsewhere. In 
diseases attended with impeded flow of blood through the lungs and heart, 
the jugular veins contain more blood, and their pulsations are visible; 
but when the impediment is extreme, the veins are in a state of constant 
distention, and no pulsation is visible. The pulsation of the arteria 
innominata — which lies in front and rather to the right of the trachea, 
just above the sternum — is seen in aortic regurgitation. Various cir- 
cumscribed swellings are noticed about the throat and neck, which are 
due to glandular enlargements; as the thyroid gland, anteriorly and infe- 
riorly, constituting goitre ; the parotid gland in the lateral superior region ; 
scrofulous lymphatic glands in the same situation; and the maxillary 
glands beneath the lower maxillary. 

IV. Various deviations from the natural configuration of the chest may 
depend on malformation of the spinal column, natural or acquired. But 
independent of deformity from this cause, the thorax may present certain 
modifications in form of semeiological value. A healthy well formed 
chest is nearly symmetrical, the two sides corresponding in shape and 
size; but, though there is no visible inequality of size, the semicircular 
measurement of the right side of the chest, at the base of the lung, 
exceeds, in adult persons, that of the left; a condition due probably to 
the influence of excess of muscular exertion on the right side ; for Dr. 
Walshe states, that in left-handed persons the left side sometimes mea- 
sures more, or more frequently the same as the right. It is in form a cone, 
with its narrow end uppermost ; its transverse diameter is evidently greater 
than its posterior; the post-clavicular regions are slightly depressed; 
the lower sternal region is concave in proportion to the development of 
the individual; the infra-clavicular regions are gently convex; the in- 
tercostal spaces are visible in inspiration and respiration, except in 

* Transactions of the Provincial Medical and Surgical A.< sociation, vol. xii. p. 307. 



350 



SEMEIOLOGY. 



very fat persons ; the lateral portions of the chest are equidistant from 
the median line ; so also the nipples, which should be both on the same 
line; there should be neither anterior, posterior, nor lateral deviation of 
the spinal column ; and the vertebral sulcus moderately convex from 
above downwards, is more nor less deep as the subject is fat or lean.* 
But it is common to meet with certain deviations in form, congenital 
and acquired, perfectly compatible with health. General prominence or 
expansion of one side of the thorax is usually caused by a large pleuritic 
effusion. It is most common on the left side. Local expansion, or 
bulging, is a consequence of several pathological conditions. When 
its seat corresponds to the base of either lung, it is caused by a gravi- 
tating pleuritic effusion ; when situated at the anterior superior parts of 
the chest, by emphysema ; when in the right hypochondrium, by en- 
largement of the liver ; and when in the precordial region, by effusion 
into the pericardium, or by hypertrophy of the heart. In aneurism of the 
ascending aorta, when advanced, a tumor is visible about the junction of 
the third rib with the right side of the sternum ; whilst aneurism of the 
descending aorta makes its appearance between the base of the scapula 
and the spine. According to Dr. Chambers, one of the earliest physical 
signs of phthisis is a slight bulging of the anterior and superior regions 
of the chest. 

Retraction of one side of the chest, most usually the left, is met with 
at the period of absorption of general pleuritic effusion. Long con 
tinued pressure having reduced the volume of the lung, when the effused 
fluid — the compressing material — has been removed, the lung not reco- 
vering its original size, the chest yields to atmospheric pressure. 

Depression, or local retraction, is met with at the period of absorption 
of circumscribed pleuritic effusion, and in pulmonary tuberculosis. 
Flattening and even depression of the infra-clavicular, post-clavicular, 
and upper scapular regions, occur in many cases of phthisis. 

By inspection of the chest, the mode of respiration in the patient is 
ascertained. The number of respirations in a healthy male adult gene- 
rally ranges about twenty in a minute. It is more in females and in chil- 
dren. The act of breathing is accompanied, in health, by regular motions 
of expansion and elevation of the chest. These are increased in spas- 
modic asthma, and in all affections where dyspnoea is a prominent 
symptom. They are diminished, where there is an instinctive avoidance 
of pain, as in pleurisy and pleurodynia; in paralysis of the respiratory 
muscles ; and when there is a material obstacle in the condition of the 
pleura or lung, as pneumonia, emphysema, pneumothorax, phthisis, &c. 
They are jerking when there is irregularity of muscular efforts, as in 
spasmodic asthma, obstructive diseases of the larynx and trachea, and 
pleurodynia. Respiration is quick when the movements of inspiration 
and expiration are performed with more than natural rapidity; it is slow 
when the contrary condition obtains. In natural breathing, the diaphragm 
concurs. When this muscle remains at rest, in abdominal inflammations 
and diaphragmatic pleurisy, and the act of inspiration and respiration 
is chiefly performed by the ribs, the respiration is said to be costal, or 

* Williams and Clymer — Diseases of Respiratory Organs, p. 24. 



SENSATION. 



351 



high. When, on the other hand, the action of the ribs is diminished, 
and that of the diaphragm becomes increased, causing the rise and fall 
of the abdomen, the respiration is called abdominal. 

V. The abdomen, in health, is firm and pliant, moderately resonant, and 
varies in size in different individuals. In women who have borne chil- 
dren, and in both sexes where there has been abdominal distention, from 
ascites or other causes, white lineal marks, resembling cicatrices, will be 
found in the hypogastric region. In pregnancy, a brownish discoloration, 
situated on the median line, and extending from the pubis to the um- 
bilicus, is often visible. 

The volume of the abdomen may be increased generally or partially. 
When general, it is owing to the presence of fluid in the cavity of the 
peritoneum, or to gaseous distention of the intestines. When the dis- 
tention from this latter cause is moderate, it is called meteorism; when 
excessive, tympanites. Different degrees of resonance accompany 
these symptoms; and the abdomen is elastic and resisting to the touch. 
They occur in adynamic diseases, peritonitis, intestinal obstruction, hys- 
teria, &c. Local or regional enlargement of the abdomen takes place in 
the hypochondriac regions in diseases of the liver and spleen ; in the epi- 
gastrium, in hysteria and cancer of the stomach ; in the hypogastrium, in 
distention of the bladder, ovarian tumors, fecal accumulation, and the 
various varieties of abdominal tumors. 

Diminution in the size of the abdomen happens in most chronic dis- 
eases, unless accompanied by ascites, or there exists an abdominal tumor. 
In chronic dysentery, there is extreme retraction of the parietes ; and also 
in lead colic, in which the muscles are exceedingly hard and unyielding. 

VI. The external exploration of the genital organs in the two sexes fur- 
nishes several important symptoms. The penis is enlarged in children 
suffering from vesical calculus, and who are addicted to masturbation. 
A cartilaginous hardness of the corpora cavernosa is said to occur in 
those who practice onanism. Retraction of the testicles happens in renal 
calculus. The scrotum is distended in hydrocele, hematocele, and sar- 
cocele. The labia majora are enlarged in general dropsy, and in certain 
local affections. 

VII. The extremities become immovable in paralysis, and contracted 
and rigid in softening of the brain, and in other organic diseases of that 
organ. They become cedematous when their chief vessels and nerves 
are pressed upon, and their circulation embarrassed. The articulations 
become swollen in rheumatism, hydrarthrosis, white swelling, &c. The 
limbs are diminished in size, in paralysis (§ 534). 

We shall now proceed to consider the semeiology of the various func- 
tions. 

VIII. The signs furnished by the nervous system in disease, are of 
great value. We shall begin with the modifications of general sensi- 
bility, or common sensation (§§ 132, 133). 

Sensation is morbidly augmented in acute inflammatory affections of 



352 



SEMEIOLOGY. 



the brain and spinal marrow; in the idiopathic fevers; in hysteria; and 
the so-called magnetic condition. Pain is at once an exaltation and 
perversion of sensibility, and is better understood than defined. There 
are several varieties of pain: L. Tensive, with a feeling of distention, 
and is felt whenever parts are put on the stretch. It occurs especially 
in phlegmonous inflammation, and is generally accompanied with throb- 
bing. 2. Dull or heavy, when accompanied by a feeling of weight; it 
is experienced when there is enlargement of some of the viscera, an 
internal tumor, or effusion into the serous cavities. It is felt in the loins 
previously to menstrual and hemorrhoidal discharges. 3. Smarting, 
when the skin has been deprived of its cuticle; or when some irritant 
has been applied to the unprotected skin. 4. Lancinating, characterized 
by sharp, pungent, transient darting; and occurs in cancer and neural- 
gia. 5. Boring, resembling the sensation which a wimble or screw 
would produce in entering and turning on itself in the suffering part; 
and accompanies constitutional syphilis, rheumatism, gout, inflammation 
of the periosteum, &c. 6. Burning, felt in burns and scalds, and in 
anthrax, and in gangrenous erysipelas. 7. Contusive, similar to that 
felt after extensive bruises, and is a constant prodromic phenomenon in 
acute diseases. 8. Tearing or pungent, compared to the sensation pro- 
duced by opening the hps of a wound ; 9, and finally, pain may be spe- 
cial in its character, as that experienced in hemicrania ; during labor, or an 
amputation ; or from a blow upon a superficial nerve, as the cubital, at the 
elbow. Itching is a peculiar exaltation and modification of sensation, seated 
in the skin, occurring principally in cutaneous affections. Formication 
is another perversion of the sensibility of the skin, and is so called from 
its resemblance to the feeling produced by the crawling of innumerable 
ants over the body. 

Common sensibility may be diminished or abolished, the latter consti- 
tuting anesthesia. Diminution or loss of sensibility may be general or 
local ; it may or may not be accompanied by diminution or loss of motion ; 
and it may be organic or functional. 

The special senses may be exalted, impaired, or perverted. Exaltation 
of vision occurs in ophthalmia and inflammation of the brain and its me- 
ninges, and some nervous affections. This sense is diminished in many 
diseases, and totally abolished in some affections of the eye and brain. 
It is variously perverted in a number of maladies. Objects having no 
existence being procured, as sparks or flashes of light, floating specks 
(muscce volitantes), or dark waving lines, and connect with affections 
of the brain and optic nerve, as well as in dyspepsia; or the proper hue 
of objects may be changed; or one-half only of the object looked at may 
be visible [hemiopsia) ; or it may seem double [diplopia). 

The hearing is often painfully acute in cerebral inflammations, and in 
hysteria; it is obtuse in typhus fever; and may be impaired or entirely 
lost in certain affections of the organ of hearing. It may be perverted 
in two ways; unreal sounds may be heard, as ringing of bells, buzzing, 
falling of water, noise of wind, &c. ; or sounds which are actually heard, 
are not appreciated or recognized. 

Smell may be exalted, diminished, and perverted. 

Taste is rarely augmented in disease, but very commonly impaired 



MOTILITY. 



353 



in acute disease, totally lost at the close of* severe affections, and va- 
riously perverted in numerous instances. 

The power of voluntary motion, or motility, may be increased, dimin- 
ished, abolished, or perverted (§§ 140, 141, 142). 

Increase of muscular strength takes place sometimes in the course of 
acute disorders accompanied by delirium, in cerebral inflammation, and 
in mania. Muscular debility attends most diseases, and may depend 
on a variety of causes, organic and functional. Complete abolition of 
voluntary motion constitutes paralysis. It may be indicative of lesion 
of the brain or of the spinal marrow, as apoplexy, spinal-softening, 
&c, or of injury to a nervous trunk; or it may be only functional, as 
happens in some cases of hysteria. It may be partial or general: if it 
affect one side of the body it is called hemiplegia; if the lower half of the 
body, paraplegia. Perversions of motility consist, 1, in trembling, — a 
feeble involuntary agitation of the muscles involved, — and occurs in the 
cold stage of fevers, in nervous affections, ataxic fevers, and in old per- 
sons ; it is caused, too, by the action of lead and mercury on the sys- 
tem, and by the prolonged use of strong coffee, alcoholic liquors, tobacco, 
and opium ; 2, rigidity, in which there is diminution of muscular 
power, and gradual rigid contraction of the flexor muscles of the limbs. 
Rigidity of the upper extremities is a symptom of softening of the brain. 
This symptom occurs too in cerebral extravasation, and in hysteria. 

The reflex or excitomotory system furnishes numerous symptoms of 
value. Its functions are exalted and perverted in spasm or convulsions, 
which may be tonic or permanent, or clonic or transitory. 

Cramp is a variety of tonic spasm, and consists in a sudden but per- 
manent contraction of one or more muscles, accompanied by hardness of 
the tissue and numbness, and inability to execute any movement of the 
affected part. The muscles of the calf of the leg and of the abdomen, 
are its chief seat. Pregnant women suffer especially from it, as well as 
those in whom an ovarian tumor may exist. It accompanies hysteria 
and painters' colic. When it occurs in old persons it is said to betoken 
cerebral softening. Many persons in health suffer from it. 

Tetanus is another form of tonic spasm. Muscular contraction here, 
is equal and permanent, the affected muscles being in a state of absolute 
immobility, which no internal or external effort can overcome. When 
the muscles of mastication only are affected, it is called trismus ; if the 
anterior muscles of the body, causing flexion, or curvature of the head 
and trunk forwards, emprosthotonos ; if the posterior muscles, bending 
the body backwards, opisthotonos ; or if the muscles of one side contract 
more powerfully than those of the other, so that the curvature is lateral, 
pleurosthotonos . 

In catalepsy the flexor and extensor muscles are in a state of permanent 
contraction, and the part implicated retains, during the whole attack, the 
position that it assumed at the moment of seizure, no matter how uncom- 
fortable that may be. 

Clonic spasm in which contraction and relaxation rapidly alternate, is 
seen in convulsions occurring in children, hysterical females, and in some 
affections of the brain ; and in subsultus tendinum, an involuntary and 
instantaneous twitching of the muscles, taking place in acute diseases of 
23 



354 



SEMEIOLOGY. 



an ataxic form, more observable at the wrist than elsewhere. Hiccup 
is probably involuntary reflex contraction of the diaphragm. Defective 
reflex or excitomotory action is seen in paralysis of the sphincters, respi- 
ratory muscles, &c. (§ 154). 

Morbid rhythmical movements of different parts of the body — as bow- 
ing movements of the trunk, rotatory movements of the head, vibration 
of a single limb, and other anomalous motions, — are sometimes noticed, 
and are considered by Dr. Paget to arise from disease of the cerebellum, 
or its commissures.* 

Reflected or sympathetic sensations, where the impression made at one 
point is felt in another, as, the pain at the extremity of the penis due to 
calculus of the bladder, and other well known instances, have been 
already mentioned (§ 156). 

The affective, perceptive, and intellectual faculties, are variously 
affected in disease. More or less mental dejection, disquietude, and 
impatience are always manifested. 

The affective functions maybe exalted in hypochondriasis, the patient 
being readily excited to strong hatred or profound friendship, or rea- 
dily moved to tears on the expression of good-will towards him, and as 
easily aroused to suspicion and dislike. Moral sensibility is, on the 
other hand, sometimes totally abolished in mania and typhous fever, per- 
fect indifference to self, and to those about the patient, being manifested. 
Perversion of the character and affections is sometimes met with in dis- 
ease, amiable persons becoming irritable and peevish, the brave, timid, 
and the pusillanimous, resolute. 

Perversion of the perceptive faculties accompanies commonly insanity, 
and consists in illusion and hallucination. 

Exaltation of the intellectual functions is often a prominent symptom 
in melancholia, and sometimes occurs at the close of life, particularly in 
acute affections. Diminished or enfeebled action of these faculties is more 
common in disease than the opposite condition. It constantly occurs in 
typhous fever. Perversion of the intellect constitutes delirium. Delirium 
is more common in the affections of infancy and youth, and in individuals 
of great nervous susceptibility. It is met with in diseases of the brain 
and its meninges, and in typhous fever, the exanthemata, and diseases 
of the chest and abdomen, as a sympathetic affection. It may be furious, 
mild, taciturn, or loquacious; and may be constant or transient; in the 
latter case it may recur at regular intervals. 

The symptoms furnished by sleep, are complete suspension of sleep, 
{insomnia ;) somnolency or drowsiness, noticed in typhoid fever, and some 
cerebral affections; coma, of which there are two varieties; 1. Coma vigil, 
accompanied by delirium, muttering and jactitation, the eyes being closed, 
except when the patient is spoken to; 2. Coma somnolentum, in which 
the patient speaks only when aroused ; lethargy, a constant and more 
profound sleep, from which the patient may with difficulty be aroused, 
but seems unconscious, and speedily relapses; and cams or total insen- 
sibility. 

The voice rarely becomes stronger in disease, but may in delirium. In 

* Edinburgh Medical and Surgical Journal, Jan. 1847. 



DYSPNCEA. 



355 



most maladies it is weaker, especially in those of the vocal and respira- 
tory organs. It may be entirely lost, constituting aphonia; or become 
hoarse, as in angina of the throat ; or shrill, or whistling, or nasal. 

The speech is often affected in disease. It is trembling in some mala- 
dies, and slow or difficult in others, as typhous fever. Stammering or 
defective articulation occurs in fevers and cerebral affections. 

IX. The semeiology of the respiratory organs is so vast and important, 
as to demand for its appropriate treatment a separate chapter. An 
outline only will be given here. 

Amongst the so-called vital symptoms (§ 606) dyspncea, cough, and 
expectoration may be enumerated. 

Dyspncea, or difficult or disordered breathing, is a symptom of great 
importance in affections of the lungs, and demanding every attention. 
It may be due to the causes, which, when excessive, produce asphyxia 
(§§ 134, 135, 136). The subjoined tabular view, by the author, of the 
causes of dyspncea, showing the varied nature and origin of the symp- 
toms and diseases it is met with in, is taken from another work.* 



PROXIMATE CAUSES OF DYSPNCEA, OR DIFFICULT BREATHING. 

1. Bt impedixg the access of pure air to the ltogs. 
a. Mechanical. 

Rigidity of parts of the re-) ( Ossification of cartilages; induration of the pleura; 
5 I rickety distortions. 

e.g. Tumors or dropsies of the abdomen. 

C Effusions in, swellings of, tumors pressing on, 
e.g. < the air-tubes. 

( Spasm of the glottis; spasm of the bronchi. 

( Pleurisy, 

Effusions or tumors in pleural! Hydrothorax, 
sac ) Pneumothorax, 

(_ Aneurism, &c. 

' Engorgement of the vessels. 

C (Edema, 

Effusions < Hepatization, 

( Tubercle, &c. 
C Emphysema, 
Altered structure < Dilated bronchi, 

( Vomicae, &c. 



spiratory machine 
Pressure on ditto - 

Obstructions of the air tubes 



Compression of the lungs 



Alterations in the tissue of 
the lungs 



e.g 



b. Chemical. 

Deficiency of oxygen in the ) 
air - 5 

c. Vital. 

Pain of parts moved in respr 
ration - 



\g. Mephitic gases ; rarefied air. 



;g\ Pleurodyne; pleuritis; peritonitis, Sec. 



~ . . _ , r -j.' £ ; ( Injuries of the spinal marrow in the neck, &c. 

Paralyse of muscles of ditto e.g. J q{ ^ (?) 

Weakness of ditto - e.g. Excessive prostration from ataxic fevers, &c. 

Spasm of ditto - - e.g. Tetanus ; spasmodic asthma, &c. 

2. Bt the state or the blood. 

a. Mechanical. 

Obstruction to the passage of ) g C Diseases of the heart and great vessels ; tumors 

the blood - - 5 C pressing on them. 

b. Chemical. 

An excessively venous state eg. Violent exertion; idiopathic dyspncea (?). 

Deficiency of red particles e.g. Anaemia; chlorosis. 



* Williams and Clymer — Diseases of the Respiratory Organs, p. 91. 



356 



SEMEIOLOGY. 



3. Bx THE NERVOUS RELATIONS OF RESPIRATION. 

Excessive sensibility of the 5 Hysteric dyspnoea; cerebral fevers; neuralgia (?). 

par vagum > • > o w 

Defective ditto - - e.g. Coma ; narcotism, &c. (breathing slow.) 

Dyspnoea may come on gradually or insidiously, or it may be violently 
sudden. The sensation is peculiar and distressing. When continuous, 
though but slight, it is singularly fatiguing and exhausting; but when 
severe, even when paroxysmal, it causes intense suffering, attended with 
a feeling of impending death. There are several degrees of dyspnoea. 
When the respiratory efforts of the patient do not oblige him to remain 
seated, it is simply laborious breathing. Orthopnea is the highest degree 
of difficult respiration, in which immediate suffocation seems threatened, 
and the erect posture is imperatively and instinctively assumed. 

Cough is generally symptomatic of disease of the air passages, but it 
is believed by many, that it may also depend on an affection of other 
organs, as the stomach, liver, &c, and thus be sympathetic. 

The tone or special character of cough varies, and may be hollow or 
harking, heard in the last stages of consumption, chronic bronchitis, and 
sometimes in nervous affections ; sharp or ringing, as in croup ; hoarse, 
in incipient catarrh, chronic laryngitis, and anginose affections; wheezing 
as in asthma ; or belching, in certain diseased conditions of the larynx. 
It is sometimes paroxysmal, as in hooping cough, and hysteria. Cough 
may be dry, attended with no excretion, or humid or moist, with more 
or less secretion into the air-tubes. 

The auscultation of the cough in health gives a quick, short, com- 
monly dull and indistinct, somewhat diffused sound, without hollow or 
tubular character, but attended with a distinct sensation of succussion 
of the interior of the thorax (Walshe). The modifications^caused by 
disease are — 1. Bronchial, which, is harsh, rapidly evolved, very concen- 
trated, with marked succussion, and slight impulsion, and is met with in 
phthisis, pneumonia, pleurisy, and dilatation of the bronchi. 2. Cavern- 
ous, characterized by its metallic character and perfect hollowness ; strong 
impulsion, and transmission of sound towards the ear of the listener; 
and accompanies tubercular excavation and dilated bronchi; and 3. 
Amphoric, of a metallic or ringing character, symptomatic of broncho- 
pleural fistula, and large tubercular excavation in the lung. 

Spitting is the act by which the saliva, and other matters in the mouth 
are rejected. By expuition, or hawking, the mucus, &c, accumulated in 
the pharynx and posterior nares is got rid of, and is attended first by a 
peculiar inspiratory, snuffing effort, and subsequently with a guttural 
cough. Expectoration, an effect of cough, signifies the expulsion of any- 
thing from the air-passages. The sputa are the matters which come from 
the bronchi, trachea, larynx, pharynx, and posterior nares, and are re- 
jected by these different modes. Their character furnishes very instructive 
signs, and may be studied with reference to quantity, consistence, form, 
composition, color and odor in pulmonary disease. They are scanty in the 
first stage of acute affections of the lungs, and may be entirely wanting; 
they are more copious in the decline of acute or subacute disease of the air- 
passages and lungs; and are abundant in many chronic diseases of these 
organs. In bronchorrhoea, a pint or more of clear, slightly viscid, and 



SPUTA. 



357 



frothy mucus may be expectorated. They vary in consistence, and may 
be serous or watery, in the forming stage of bronchitis, pulmonary con- 
gestion, and vesicular emphysema; mucous, more or less viscid, and the 
result of acute inflammation of the mucous lining of the air-tubes, and 
of the pulmonary parenchyma, and hence met with in bronchitis and 
pneumonia; and purulent, of the consistence of pus, due to the discharge 
of an abscess into the air-tubes, and seen in phthisis, and the third stage 
of pneumonia. The form of the sputa depends very much on their con- 
sistence. When viscid they are elongated, stringy, and stellated; they 
are sometimes frothy, flattened, and run together in the vessel, forming a 
homogeneous mass ; and again they may be distinct, rounded, almost 
hemispherical, as the so-called nummular sputa, so often seen in the ex- 
pectoration of tubercular phthisis, the bronchitis of measles, and oc- 
casionally in chronic bronchitis. The sputa sometimes are moulded 
into the shape of the tube or cavity from which they come. The large, 
rounded, flocculent, muco-purulent sputa of advanced phthisis, are often 
such as could only accumulate in a cavity (Williams). Tubular sputa 
are coughed up in plastic bronchitis and pneumonia. Remak asserts, 
as the result of his observations, that the sputa of pneumonia invariably 
contain ramifying bronchial coagula, which appear in the majority of 
cases between the third and seventh day of the disease, being rarely 
absent on the fourth and fifth. The basis of the sputa is usually the 
secretion of the mucous membrane of the air-tubes. Its composition 
varies with the altered products of secretion, and from the admixture of 
extraneous matter, as blood, tubercular matter, &c. There is great va- 
riety in the color of sputa. In the beginning of acute affections of the 
lungs, they are whitish, or ashen ; in acute bronchitis, when secretion 
occurs, they are yellowish or greenish ; in pneumonia they are reddish 
or ' rusty, yellowish, or brownish, resembling prune juice, from the ad- 
mixture of blood. In bronchitis and the first stage of phthisis, the odor 
of the sputa is faint and sweetish. When secretion is copious in catarrh, 
the smell is sickening. When purulent matter is expectorated, the odor 
is fetid. In gangrene of the lungs, it is distinctive, and putrid. When 
an alliaceous odor is perceptible it is a sign of broncho-pleural fistula. 
An urinous smell of the sputa has been sometimes perceived, and two 
cases in which it existed, have been described by Drs. Haen and Stille, 
in which, on examination after death, a continuous passage from the 
bladder to the lung, was found. When a direct communication exists 
between the liver and the lung, as occasionally happens, the sputa may 
be bilious. 

Pain is another vital symptom connected with disease of the organs 
of respiration. In acute bronchitis, there is usually a dull, heavy, aching 
pain, around the base of the chest, which is generally pretty constant. 
Soreness, too, is complained of in the sternal region and between the 
shoulders. Pleuritic pain is sharp, lancinating and sudden, and felt be- 
low the nipple. In phthisis, patients complain of darting pains from the 
anterior regions of the chest to the interscapular regions, and frequently 
about the clavicular regions, which are probably due to pleuritic com- 
plication. Constant pain between the shoulders is commonly regarded 
as a symptom of phthisis, but in Andral's opinion it is merely muscular, 



358 



SEMEIOLOGY. 



due to debility, and met with in many chronic diseases, particularly 
chlorosis. 

Physical exploration of the chest includes palpation or the applica- 
tion of the hand, mensuration, percussion, and auscultation. By the ap- 
plication of the hand, we not only obtain results confirmatory of those 
ascertained by inspection, with regard to alterations of form and of mo- 
tion (p. 350), but also diagnostic indications derived from thoracic fremitus 
or vibration, and the presence of fluctuation in the pleural cavities. By 
mensuration we are enabled to detect with greater accuracy than by 
inspection, the inequalities of size in the two sides of the chest, already 
spoken of. 

So much for the examination of the chest by sight, touch and mea- 
surement. We now come to its examination by hearing. There are 
certain sounds elicited from the chest by striking it {percussion), and 
others which are produced by the act of respiration, and the exercise 
of the voice, and which we become cognizant of, on applying the ear 
directly to the thorax {immediate auscultation), or with the interposition 
of a cylinder of wood, called the stethoscope {mediate auscultation). 

In health, the chest on being smartly struck, is generally resonant, 
although not to an equal degree in all portions. Those regions which 
are most thickly covered will sound duller than those more lightly coated. 
Whilst the axillary, upper-sternal, and infra-clavicular regions are very 
resonant from their light covering of muscle and fat ; the acromial, infra- 
scapular, lower sternal, and left mammary are imperfectly resonant, or 
dull. The modifications of sound, elicited by percussion in disease, are 
few. There may be increased clearness of sound, caused by diminished 
density of the subjacent parts, and an increased proportion of air within 
the chest, as in pneumothorax and emphysema; or there may be diminu- 
tion of clearness or even positive dullness, owing to an opposite condition, 
as in pneumonia, pleurisy, phthisis, hydrothorax, &c. But, in certain 
diseases of the chest, sounds of a special character are elicited by per- 
cussion : 1, the wooden, resembling that yielded by mediate percussion 
of a table, and heard in chronic pleurisy with dense membranes; 2, the 
tympanitic, unnaturally clear and hollow, owing to the increased quantity 
of air beneath, and met with in pneumothorax and pulmonary emphy- 
sema; 3, tubular, resembling the sound emitted by the trachea when 
percussed ; it occurs, when the larger bronchi are brought near to the 
surface, as in pleuritic effusion, and where tubercular cavities exist : 4, 
amphoric, which may be imitated by filliping the cheek, when the mouth 
is closed and fully inflated, and is observed in large tuberculous cavities; 
5, the cracked-metal, — bruit-de-pot yHe—-resembling the amphoric, but 
peculiar and distinctive, similar to the sound produced by striking a 
broken pitcher, and happening in large tuberculous excavations near the 
surface. Percussion gives another valuable indication, too generally 
overlooked, — the sensation of resistance in the part percussed — depending 
on increased density in the subjacent lung. Where the sense of touch 
is more delicate than that of hearing, this source of diagnosis is of great 
value. In acute phthisis, where, from the similar condition of both 
lungs, there is no means of comparison, it is often a precious sign. 

By pulmonary auscultation is meant, the listening to the sounds pro- 



BRONCHI. 



359 



duced in the lungs by the respiratory function. These consist in modi- 
fications of the natural respiratory murmurs, and adventitious sounds, 
which supersede them, called rhonchi. Natural respiration may be 
variously altered. It may be exaggerated — increased intensity of the 
inspiratory and expiratory murmurs, — and occur in. the portions of lung 
adjoining those rendered unfit for the purposes of respiration, by obstruc- 
tion, condensation or rarefaction. It is sometimes called supplementary 
respiration. Weak respiration is diminished intensity and duration of 
the respiratory murmurs, caused by the existence of an obstruction to 
the entrance of air in the part where it exists. The respiration may be 
totally suppressed, no air entering the region where it is met with, as 
where a plug of hardened mucus fills up a large bronchus. It is some- 
times incomplete, the inspiratory murmur being deficient at its beginning 
or close; this accompanies spasmodic asthma. Jerking respiration is 
where the inspiratory murmur is interrupted, and not evenly continuous, 
and is met with in incipient pleurisy, spasmodic asthma, and certain 
cases of tuberculous infiltration. Bronchial respiration resembles the 
natural respiration heard where the large bronchial tubes exist — the 
top of the sternum and root of the lung; both murmurs are blowing, 
harsh and dry, with increased intensity and prolonged expiration; it 
accompanies condensation of the pulmonary tissue, and occurs in pneu- 
monia, tubercles, &c. The respiration is said to be cavernous when 
it resembles the sound produced by blowing into a hollow vessel; and 
amphoric, when it gives the sensation of air passing into a large empty 
cavity, and maybe imitated by blowing into a jug two-thirds full. They 
are met with in large tuberculous excavations. 

The various rhonchi are sounds which mask or suspend the natural 
murmurs of respiration, originating in the bronchi, and excavations of 
the pulmonary tissue, and caused by the passage of air along bronchi of 
altered calibre, or by air bubbling through fluid contained in these tubes, 
or in cavities in the lung. The rhonchi are either dry or humid. 

C Sibilant, 
Dry < Sonorous, 



Rhonchi 



Dry crackling 
f Crepitant, 



Humid J S" bcre P ita ^ 
1 Mucous, 

Cavernous. 

The sibilant and sonorous rhonchi are present in bronchitis, unaccom- 
panied by secretion, and are produced by the modified calibre of the air- 
tubes. Dry crackling rhonchus is composed of a succession of minute, 
dry, short, sharp, crackling sounds, few in number, rarely exceeding 
three or four in a respiration, coexisting with inspiration. (Walshe.) It 
is heard in the first stage of phthisis, and is indicative of unsoftened 
tubercle in moderate quantity. 

Crepitant rhonchus resembles the sound produced by rubbing a lock 
of hair between the fingers, near the ear, or by the crepitation of salt on 
coals. It is the physical sign of pneumonia in the stage of engorgement, 
and in that of resolution. In subcrepitant rhonchus, the sound is more 
moist, and gives the idea of a greater amount of liquid. It is caused 



360 



SEMEIOLOGY. 



by the passage of air through minute bronchial tubes containing liquid, 
of variable consistence. It occurs in capillary bronchitis, idiopathic, and 
tubercular ; pneumonia, at the period of resolution ; pulmonary apoplexy ; 
and oedema of the lung. Mucous rhonchus is produced by bubbles of 
large size traversing liquid in bronchi of moderate or large size. Ca- 
vernous, or gurgling rhonchus, is the bubbling of air through liquid, in 
a pulmonary cavern, and has a peculiar, hollow, metallic sound, and 
attends tuberculous excavations. 

When the surfaces of the pleura become changed by disease, sounds 
are produced, giving the sensation of friction, whi ch may be detected by 
auscultation. 

On the application of the ear to the healthy chest, when an individual 
is speaking, a diffused buzzing is heard ; except over the upper part of 
the sternum, over the large bronchial tubes, and on the middle line pos- 
teriorly, over the division of the trachea, and on either side of that divi- 
sion between the spines of the scapula, and in the axilla, where the voice, 
imperfectly articulate, is transmitted with some degree of force and dis- 
tinctness, constituting natural bronchophony. In disease, several modi- 
fications of vocal resonance occur. It may be diminished in intensity, or 
be entirely suppressed, from the feeble conducting power of the substance 
of the lung, or intermediate substance, as in vesicular emphysema, and 
pneumothorax; or, it maybe exaggerated, constituting bronchophony — 
the unnatural density of the pulmonary tissue surrounding the bronchi 
rendering it a better conductor of sound. This happens in tuberculous 
accumulation, and in pneumonia in the stages of hepatization. There is a 
peculiar modification of vocal resonance, to which Laennec gave the 
name of cegophony, from its tremulous, nasal, and metallic tone, resem- 
bling the bleating of a goat. It is audible over a limited surface, and 
its position may alter with the posture of the patient. The physical 
cause of this sign is generally a thin stratum of fluid usually contained 
in the pleura, and it of course is a sign of pleurisy, after effusion has 
taken place. Pectoriloquy signifies a state of vocal resonance in which 
the voice appears to resound in a hollow space, and is transmitted as 
articulate words to the ear of the observer. In its most perfect state, the 
patient appears to speak directly into the ear. {Walshe.) The presence 
of an excavation, or dilated bronchus, whose condition permits free vibra- 
tion, is necessary for its production, and it is present, therefore, in tuber- 
cular" caverns, and dilated bronchi. When the vocal resonance has a 
strong metallic tone, it is called amphoric, from its similarity to the phe- 
nomenon produced by speaking into an empty pitcher. It is heard in 
the same affections as amphoric respiration. 

If the surface of the chest be auscultated during the cough of a healthy 
person, a short, dull, and indistinct, and diffused sound, quickly produced, 
is heard, attended with a sensation of succussion of the interior of the tho- 
rax. The morbid modifications of pulmonary cough are three : bronchial, 
cavernous, and amphoric. Bronchial cough is harsher and more concen- 
trated than the cough in health. It is met with, wherever there is unna- 
tural density of the lung; when it is compressed by fluid ; or the bronchi 
are enlarged ; — as in phthisis, pneumonia, pleurisy, and dilatation of the 
bronchi. Cavernous cough has a hollow and metallic character, and 



IMPULSE OF THE HEART. 



361 



gives the sensation of being produced in a small excavation; there is 
strong impulsion in its transmission to the ear. It is associated com- 
monly with cavernous rhonchus. Amphoric cough is loudly resonant 
and metallic in its character. It occurs under the same circumstances 
as amphoric respiration. 

There is one phenomenon, detected by auscultation of the chest, which 
is common to the sounds of the respiration, of the voice, and of the 
cough — metallic tinkling. It is a quick, sharp, ringing sound, closely 
resembling that produced by gently striking a hollow metallic, or glass 
vessel, with a pin. (Walshe.) It is heard in pneumo-hydrothorax, with 
bronchial fistula, and it is said, sometimes, in certain excavations of the 
lungs. 

X. The signs derived from the circulatory system include those of the 
heart and arteries. By auscultation of the heart, we study its impulse, 
its rhythm, and its sounds. By applying the fingers, or ear over the space 
between the fifth and sixth ribs, a little to the inner side of a line run- 
ning vertically over the nipple, a gentle and regular pulsation, synchro- 
nous with the pulse at the wrist, is perceived, and a slight shock felt. 
This is the impulse of the heart. It varies slightly with the position of 
the patient. The character of the impulse of the heart differs consider- 
ably in individuals, irrespective of disease. "It is full and power- 
ful in the strong and robust ; while in the w r eak and delicate, it sometimes 
amounts to scarcely more than an undulation, the precise situation of 
w r hich it is sometimes difficult to determine. In the vigorous, but calm 
individual, it is strong, heaving, and diffused; in the weak, nervous, and 
excitable, it is smart, smacking, and very defined, or as it were, concen- 
trated ; when, indeed, the organ itself, and the arteries leading from it 
are healthy, the impulse of the heart resembles in character and power, 
as well as in frequency, the pulse at the wrist."* A smart, or smacking 
impulse should not be confounded with a forcible, or heaving one. The 
first is indicative of an irritable, and, usually, a weak heart, whereas a 
deep, heaving impulse, accompanies a full or hypertrophied heart. In 
disease, as in health, a close correspondence will be observed between 
the impulse of the heart, and the pulse at the wrist, unless some mecha- 
nical impediment exists to the course of the blood. In fevers and in- 
flammations, w T hen the pulse is strong, so is the heart's impulse; when 
the pulse is feeble and depressed, the impulse is so likewise: and 
w'hen the pulse is small and vibratile, after hemorrhage, in anaemia, 
&c, the impulse manifests the same quality. In simple hypertrophy, 
the impulse is full, strong, and heaving, lifting the head of the lis- 
tener from the chest, and somewhat diffused. In hypertrophy with 
dilatation, the impulse is more powerful, and may be often felt over 
the whole precordial region. In simple ventricular dilatation, the im- 
pulse is feeble, scarcely amounting to more than a gentle tremor, but 
greatly diffused. In anaemic and nervous persons, or in atrophy of the 
muscular w T alls of the heart, with fatty degeneration (§ 544), the impulse 

* A Clinical Introduction to the Practice of Auscultation, &c. By H. N. Hughes, M.D., 
p. 202. 



362 



SEMEIOLOGY. 



is often exceedingly sharp, smart, and concentrated. When obstruc- 
tion to the circulation exists anterior to the tricuspid valve, the impulse 
is visible at the scrobiculus cordis. When the mitral valve is diseased, 
and there is partial regurgitation through the left auriculo-ventricular 
opening, along with the impulse at the scrobiculus cordis, there is fre- 
quently perceptible impulse between the cartilages of the third and fourth, 
or even second and third ribs of the left side. In pericarditis, the 
impulse varies in degree and situation with the amount of effusion. 

When the ear is placed on the precordial region, a regular succession 
of sounds is heard, with regular intervals — a long sound, a short sound, 
and an interval, making a complete circuit of the heart's function. The 
regular performance of this constitutes the rhythm of the organ.* W T hen 
the proper relation of the sounds to each other and to the interval is pre- 
served, the rhythm is natural; when such relation is disturbed, and there 
is an alteration in the natural succession of sounds and intervals, the 
rhythm is unnatural, and the action of the heart is said to be irregular. 
When this irregularity recurs at stated intervals, it constitutes intermittence. 
Anything which unnaturally excites the action of the heart, as a moral 
impression or physical impediment, may disturb its rhythm. The most 
frequent cause of altered rhythm in disease, is valvular change. In 
great dilatation of the heart, and atrophy of the walls of the ventricles, 
the rhythm is altered; as well as in large effusions into the pericardium. 

The natural sounds of the heart, it has been already stated, are two; 
the first, dull and prolonged ; the second, short and sharp, with hardly 
an appreciable interval between them, and may be fairly represented by 
the syllables lub-tuh — lub-tub. Now the tone of these sounds may be 
unnaturally increased, or become louder as well as clearer, as in dilatation 
of the cavities, with thinning of the walls, without valvular disease ; when 
the sounds are only clearer, or shrill, there is only muscular atrophy of 
the parietes. A decrease in the cardiac sounds may be due to several 
causes; — as whatever interferes with the free action of the heart, or its 
valves; and preternatural thickening of the walls, or hypertrophy. The 
natural sounds of the heart may in disease become masked, or be re- 
placed by unnatural sounds, called murmurs. These murmurs depend 
on conditions existing either in the cardiac cavities, or within the heart ; 
or in the pericardium, or outside of the organ. 



Endocardial \ Blowing 
Murmurs ) Murmur 



Bellows murmur 
Rasping " 
Filing " 
Sawing " 
Musical " 



Exocardial ( Rubbing murmur 
Murmur \ and its varieties. 

The endocardial murmurs are indicative 1st, of valvular lesions; 2d, 
of diseases of the constituents of the blood, as anaemia, &c. ; and 3d, of 
nervous disease of the heart. The exocardial murmur, which is always 
a friction sound, results from the attrition of two roughened surfaces, and 
is symptomatic of pericarditis. For further information regarding the 

* Carpenter's Principles of Human Physiology, 3d edit , p. 549. 



PULSE. 



363 



semeiotic value of these murmurs, the reader may consult the numerous 
special works on the subject. 

The influence of disease upon the pulse is very great ; and the differ- 
ent varieties of pulse are amongst the most valuable signs (§ 607). 
A great variety of pulses have been described, but all the important 
modifications of the pulse in disease may be included under two heads. 
1, the force and intensity of the pulsations; and 2d, the rhythm or rela- 
tion of the pulsations to each other. A strong pulse is that which resists 
compression by the finger, and accompanies inflammatory affections, par- 
ticularly of the parenchyma of the solid viscera, as the lungs and liver; 
and the active hemorrhages. The condition of the vascular system 
at the time of attack, influences the production of this form of pulse. 
In plethoric individuals, and those of strong constitution, anything which 
deranges the circulation will cause a strong pulse ; and therefore it should 
not be always taken as an indication of the degree of inflammation. A 
weak pulse, where the artery is easily compressible, is met with under 
different circumstances; as in all diseases attended with prostration, and 
in nervous and chronic affections, especially when caused by perverted 
nutrition. It may be produced by fear. The diseases of children, old 
persons and women, often exhibit this pulse. A full pulse is where the 
volume of the artery seems increased. It is the natural pulse of ple- 
thoric, thin, and tall persons, and occurs in all those diseases in which 
the pulse is strong, as well as in cerebral congestion and apoplexy, and 
in cardiac disease, particularly hypertrophy, with valvular complication. 
A small pulse gives the sensation of diminished diameter on being felt. 
It is caused often by narrowing of the aortic orifice, and when present, 
should induce examination of the heart. It is the pulse of the serous 
phlegmasia?, as peritonitis, pericarditis, inflammations of the stomach, 
intestines, bladder, &c. ; it is met with in hysteria, hypochondriasis, 
and other nervous affections, as well as in chlorosis ; in the cold stage of 
fevers; and in diseases attended with violent paroxysms of pain. It 
is a symptom of adynamic and ataxic diseases, and of purulent resorp- 
tion. Sometimes the artery feels like a thread beneath the finger — this 
is the filiform pulse. When a vibratory sensation is communicated to 
the finger, the pulse is said to be hard, sharp, or contracted; this is called, 
also, a corded pulse. It is encountered in the membranous phlegmasia?, 
sanguine congestions, active hemorrhages, neurosis, lead colic, &c. A 
soft, compressible, or liquid pulse, depends on a diminution of the toni- 
city of the arteries (§§ 123, 607), and yields with great readiness to 
pressure. In some adynamic affections, the pulse, though apparently 
distended, on slight compression, gives way, — this variety of the soft 
pulse has been termed gaseous, from the sensation experienced by the 
finger of the examiner. The pulse is quick, when the arterial stroke or 
diastole is very rapid, without any diminution in the intervals of pulsa- 
tion ; though generally associated with a frequent pulse, it is distinct 
from it. 

In the healthy adult the number of pulsations in a minute may be 
stated at 75; but it is liable to great variation from a number of causes, 



364 



SEMEIOLOGY. 



as position, &c* A frequent pulse is where the natural number of 
pulsations is considerably exceeded. It constantly accompanies all febrile 
and inflammatory diseases, hemorrhages, &c. A slow or infrequent pulse, 
in which the number of pulsations falls below the healthy standard, oc- 
curs in apoplexy, acute tubercular meningitis, in some adynamic affec- 
tions, occasionally in disease of the heart, &c. An equal pulse is that, 
in which the pulsations in a given time are alike in fullness, resistance, 
quickness, and velocity. The pulse is unequal, when the pulsations 
differ from each other in this respect. Inequality in rhythm is called the 
dichrotous pulse, which gives the sensation of a double beat, and has 
been compared to the rebounding of the hammer on the anvil. It is 
observed in convalescence from fever and other diseases (§ 123). When 
a pulsation or beat fails, at regular and uncertain intervals, the pulse 
is called intermittent. 

When the stethoscope is placed over a large artery, a peculiar dull 
sound is heard synchronous with the ventricular systole; this maybe 
masked or replaced by an unnatural murmur. Of all the unnatural mur- 
murs heard in auscultation of the arteries, the blowing sound, and its 
various modifications, are the most common. It most frequently occurs 
in connection with diminution of the red corpuscles of the blood, as in 
anemia, chlorosis, &c. ; but may be caused by ossification, dilatation of 
the walls of the arteries ; or from compression of the vessel by a tumor. 

XI. The signs derived from the digestive organs next claim our atten- 
tion. 

The state of the tongue in disease has always been considered of great 
importance, and has been already alluded to (§ 607). Although the 
importance of the signs which it furnishes have been exaggerated, they 
are interesting and valuable. The tongue in disease is to be studied in 
connection with its modifications in volume, form, movements, color, 
degree of moisture, nature of its coatings, its temperature and sensibility. 
Diminution in the size of the tongue is a frequent symptom in typhus 
and other low fevers; it is at the same time generally trembling and dry 
— conditions of equal- gravity. A pointed, conical tongue was once sup- 
posed sufficient to establish the existence of gastritis. Experience has 
shown, however, that it indicates neither the nature nor the seat of the 
disease, or its danger, and that it depends entirely on the manner of 
contraction of the muscles of the organ. Impeded movement and dis- 
tortion are valuable, as unfavorable signs in fevers as well as in cerebral 
disease. In paralysis the deviation is usually more apparent than real; 
its seat being the buccal commissure and not the tongue. When the 
tongue presents on its upper surface a coating, it is generally evidence 
of some morbid condition. Fasting will, in some persons, produce a 
white fur, and others w T ho sleep with their mouth open are liable on wak- 
ing, to have the tongue dry and dirty. Does the tongue faithfully repre- 
sent the state of the stomach? The results of careful and repeated ob- 
servations on the part of Dr. Louis indicate, on the contrary, a great 
degree of independence of the conditions of the tongue and stomach. 
His observations, confirmed by others, show that the aspect of the tongue 
bears no relation whatever to that of the stomach ; the same state which 

* Carpenter's Principles of Human Physiology, 3d edition, p. 555. 



FECES. 



365 



coincides at one time with decided disease of the stomach, occurs at 
others where this organ is healthy. Albuminous exudation on the sur- 
face of the tongue is unconnected with any particular state of the sto- 
mach, but is a phenomenon of singularly bad augury, as it rarely appears 
until a few days before death. It occured in one-eighth of the cases of 
phthisis observed by Dr. Louis. 

The appetite may be increased in disease to a degree constituting vo- 
racity, or bulimia, which is sometimes seen in pregnancy, hysteria, and 
insanity. Generally, however, it is diminished, and there is indifference 
[anorexia), or actual aversion to food. This is seen in most acute dis- 
eases. The appetite may be perverted, and articles which are noxious 
or disgusting may be eagerly sought after. 

Thirst is increased in acute affections, particularly of the stomach and 
bowels, after hemorrhage, and in diabetes. It is abolished in some cere- 
bral diseases, and where there is coma. 

Vomiting occurs under various circumstances. It is a frequent initial 
symptom of acute inflammatory and febrile affections. It is an early 
symptom of pregnancy; of lead, hepatic, and nephritic colic; of cerebral 
disease; and of hernia. 

Pain in the abdomen may proceed from a variety of causes ; it may be 
due to inflammation of some of the contained viscera, and in that case 
it is aggravated by pressure; or it may depend on over distention of 
some portion of the digestive tube; on neuralgia; hepatic, renal, intesti- 
nal, and lead colic, and is then generally relieved by pressure. 

Dysentery is often attended with a sharp burning pain, with a strong 
desire to go to stool; this is called tenesmus. Acute colicky pains are 
termed tormina. 

The feces frequently undergo very important modifications. Their 
consistence when liquid may vary from that of water to that of pap. 
They are watery in serous diarrhoea, and Asiatic cholera ; in chronic in- 
flammation of the. colon they are mucous, and resemble white of egg. 
Sometimes they are harder than in health ; this is particularly the case in 
lead colic, and also, it is said, in cancer of the stomach. In these diseases 
they often resemble the excrement of sheep, forming small, black, hard 
balls. The color of the feces varies. When there is deficiency of bile, 
they are of a grayish-white or clay-color; when it is in excess, they are 
yellow or dark brown ; a dark greenish hue is commonly thought to depend 
upon the presence of bile, and this is particularly observed in children 
after the administration of calomel, but Dr. Golding Bird has shown it to 
be due to the presence of blood. Rhubarb stains the feces yellow. In 
dysentery they are reddish, or streaked with blood. When the blood is 
dark, and mixed with the feces, it usually comes from the superior por- 
tion of the intestinal canal. In melsena the stools are of a pitchy black- 
ness. W T hen the blood is pure, and the evacuations are unattended with 
colicky pains, it is hemorrhoidal. The feces are semi-transparent and 
colorless in Asiatic cholera, with whitish clots, and resemble rice water or 
turbid whey. The preparations of iron give them a black color. The 
alvine evacuations may contain shreds of false membrane, — as in 
dysentery and diarrhoea, — biliary or intestinal calculi, worms, &c. In 
diabetes and phthisis they often abound in fat. In some diseases they 



366 



SEMEIOLOGY. 



become intolerably fetid. In adynamic diseases they are very offensive, 
and in chronic dysentery exhale a peculiar cadaverous odor. (For much 
interesting information on the intestinal excretions, consult Simon's Ani- 
mal Chemistry, &c, translated by Dr. Day.) 

XII. The signs derived from the urine are highly valuable, not only 
as regards the urinary apparatus, but other organs, and the system gene- 
rally (§ 607). Many of these have already been noticed, and their se- 
meiotic value indicated (§§ 167, 176, 249, 254, 255, 257, 260, 309, 384, 
385, 448, &c). We shall notice them here very briefly. 

Disease influences the quantity of urine passed. A healthy adult 
usually secretes during the day a pint and a half to three pints. In some 
affections of the kidneys there is complete suppression, no secretion taking 
place. The writer recently saw a case in which there was complete 
suppression during five days, without the supervention of coma. The 
patient recovered from that attack, but succumbed, without the occur- 
rence of comatose symptoms, to a second one; and, on examination, 
both kidneys were found extensively disorganized. In most inflamma- 
tory and febrile diseases, there is diminution in the quantity of urine, as 
well as in dropsy. Retention of urine, — where it is secreted, but re- 
tained in the bladder, — occurs as a consequence of paralysis, in typhoid 
fever, in hysteria, &c. Increase in the amount of urine takes place in 
diabetes, in the cold stage of fevers, and in hysteria. Fear, terror, and 
other passions of the mind frequently render this secretion extremely 
copious. The tints of the urine in different maladies are of importance; 
they vary from nearly colorless, to the usual pale amber color, up to deep 
brown. In chlorosis and hysteria, the urine presents a slight greenish 
hue; if bile, or blood be present, a variety of colors varying from red 
to brown, blackish-green, or apple-green, are produced — the latter hue 
being occasionally indicative of the presence of cystine. Urine some- 
times varies in consistence, and instead of its usual fluidity, acquires 
some degree of viscidity; in some cases only to be detected by the readi- 
ness with which it froths on agitation, and the length of time the bubbles 
remain, as in diabetes mellitus; and in others sufficiently so to allow of 
being drawn into threads, from the presence of mucus, or pus in very 
concentrated and alkaline urine — the alkali reacting on the albuminous 
constituents of the pus and converting it into a mucous magma, as 
pointed out by Drs. Babington and Golding Bird. In some rare cases, 
urine fluid w T hen w T arm, becomes semi-solid like jelly, on cooling, from 
the presence of albumen or fibrin; this generally betokens some organic 
renal disease, though it is said to happen also in functional disturbance. 
Dr. Golding Bird states that in a few rare instances he has found urine, 
which was quite fluid whilst cold, gelatinizing when heated; it was 
loaded with oxalate of lime. The odor of the urine in adynamic fever, 
after lesions of the spinal marrow, when long retained in the bladder, &c, 
is offensively ammoniacal. The following are the general characteristics 
of the urine in inflammatory affections : — It is darker, being of a yellow, 
brown, or reddish-brown tint; has an acid reaction; and augmented spe- 
cific gravity. The urea may be absolutely increased, at, or below the 
natural standard; the salts are always absolutely diminished. The com- 



URINE. 



367 



position of the urine becomes changed, if much blood is abstracted 
during the progress of the inflammation ; it becomes clearer, specifically 
lighter, and the amount of urea decreases absolutely and relatively. At 
the height of the inflammation, the urine is clear, and deeply colored; 
when it subsides, there is a yellow or reddish sediment of uric acid and 
urates. 

The chemical composition of the urine has within a few years attracted 
a good deal of attention, as well as its microscopical examination ; and 
by these means the several urinary deposits have been very attentively 
and advantageously studied. Deposits of uric acid and its combinations, 
present every shade of intensity of tint, from the palest fawn-color to 
the deepest amber or orange-red, and are often called red or yellow 
sand sediments. They occur in fever, in acute inflammation, in rheu- 
matism, in phthisis, in all the grades of dyspepsia, in all or most stages 
of diseases attended with arrest of perspiration ; in diseases of the genital 
apparatus; from blows and strains of the loins ; from excessive indul- 
gence in animal food; or, the quantity of food remaining the same, from 
too little exercise. The earthy phosphates (phosphate of lime, ammonio- 
phosphate of magnesia, and carbonate of lime), are always white, unless 
when colored with blood ; soluble in dilute hydrochloric acid; and in- 
soluble in ammonia and liquor potassa3. On heating the urine the 
deposit agglomerates into little masses. The occurrence of deposits of the 
earthy phosphates, should be regarded as of serious importance, always 
indicating the existence of important functional, and, too frequently, 
of organic mischief. One general law appears to govern the pathologi- 
cal development of these deposits — that they always exist simultaneously 
with a depressed state of nervous energy, often general, rarely more 
local, in its seat (Bird). Deposits of oxalate of lime are regarded by 
Dr. Golding Bird as by no means so rare as is generally supposed, and 
he believes that it owes its origin to sugar, and is caused by derangement 
of the digestive organs. The urine may contain all or any of the ele- 
ments of the blood. The serum may be alone effused, or be accompanied 
with the red globules. Whenever the elements of blood appear in the 
urine, there is ample proof of the existence of active or passive hemor- 
rhage of the kidneys or urinary tract. Albuminous urine occurs in 
Bright's disease, dropsy after scarlatina, &c. Pus is met with in the 
urine as the result of suppuration of the kidney, or of some portion 
of the genito-urinary mucous membrane, or of abscesses from adjoining 
viscera, opening into urinary cavities. The quantity of mucus in urine 
may vary under the influence of different degrees of irritation or inflam- 
mation, from a mere cloud to a viscid and tenacious fluid. The general 
indication of mucous deposits is an irritated or inflamed state of the 
genito-urinary mucous membrane. The presence of sugar in the urine 
is not uncommon in dyspepsia, and when excessive is an important sign 
of diabetes mellitus. The urine of pregnant women sometimes contains 
a whitish, opalescent, greasy pellicle, called kiestein. (Much valuable 
information on the subject of the urine in disease may be had by consult- 
ing Simon's Chemistry of Man, and the excellent manuals of Dr. Golding 
Bird, Rees, Griffith, Marcwick, &c, all of which are republished in this 
country.) 



368 



DIAGNOSIS. 



XIII. The cutaneous exhalation or perspiration, presents numerous 
points of semeiotic value. The average quantity of fluid transpiration 
is estimated at twenty-nine ounces daily, containing from seven to eight 
scruples of solid matter. Children perspire more profusely than adults, 
and men more than women. Profuse perspirations occur in acute rheu- 
matism, and towards the decline of acute inflammations and fevers, and 
in the latter case are often critical. The night sweats of phthisis are 
profuse and debilitating. The perspiration may be diminished or sus- 
pended, as during the early stage of acute disease, and in dropsy and 
diabetes. Perspiration may be general or local ; it may be confined to 
the forehead, palms of the hands, epigastrium, soles of the feet, &c. 
Local sweats are sometimes critical. A case of this kind is mentioned, 
in which the sweat stood in drops on the feet, fresh drops springing up 
as fast as the feet were wiped ; and it was curious that the surface 
affected occupied the posterior half only of each sole.* The odor of the 
perspiration is naturally slightly acid. In rheumatism and in gout this 
becomes excessive. The odor is fetid sometimes in adynamic fevers; 
mouldy in measles and scarlet fever ; and ammoniacal occasionally in 
typhoid fever. In insanity a peculiar odor has been noticed ; and that 
of miliary sweat has been compared to the smell of chlorine, or rotten 
straw. A case in which sugar was detected in the sweat of a diabetic 
patient has been recorded by Nasse. 

XIV. The symptoms furnished by animal heat, are various. The tem- 
perature of the human body may be increased ; this may be general or 
local. In idiopathic and symptomatic fever there is general heat of the 
surface (§ 437). 

In external local inflammation there is always at least the sensation of 
heat (§ 431); and the skin of the forehead is often hot in cephalalgia ; 
the scalp in cerebral disease; the integument of the chest in thoracic 
inflammations; the hands and feet in phthisis, &c. Heat may be 
permanent or transient. There are different varieties of heat. The 
acrid heat of typhous fever, giving to the hand a peculiar burning sensa- 
tion, increased by prolonged contact, is called color mordax. Diminution 
of temperature or cold, presents the same varieties in relation to its 
intensity, seat, type, and peculiar character. Coldness is a simple sen- 
sation, of cold ; horripilation is accompanied with contraction of the skin 
and the bristling of the hairs over the surface ; a rigor is attended with 
involuntary tremor. A chill of more or less intensity occurs as an initial 
symptom of febrile affections, and of the phlegmasise, particularly pneu- 
monia. In cyanosis the temperature of the body is generally low; 
and this symptom is very common when the circulation, from whatever 
cause, is languid. Nervous and anaemic persons suffer from coldness of 
the hands and feet. — C] 

611. The diagnosis of diseases is the distinction of diseases from one 
another. It may relate to diseases in their essential nature or pathology, 
or to those groups of symptoms that are classed as separate diseases by 

* British and Foreign Medical Review, vol. xx. p. 312. 



MODES OF DIAGNOSIS. 



369 



nosological arrangements (§ 597). In other words, the object of diag- 
nosis is to determine, either the intimate nature and seat of a disease, or 
its name and place in a classification of phenomena, grouped under the 
name of special diseases. According to the nosological arrangement, 
which has been recommended as the best at present (§ 600), the division 
into special diseases is, as much as is practicable, founded on pathology, 
or the essential nature of disease; and diagnosis should also have a cor- 
responding reference to this subject. But as it has been admitted that 
pathology is not sufficiently advanced to be the sole basis of nosology, 
so we must avail ourselves of other sources of information in regard to 
diagnosis. Accordingly, much of the materials of diagnosis are the 
results of simple observation or clinical experience ; and where these 
cannot be analyzed by any more rational mode, they may be measured 
or valued by the numerical method, or counting and calculating the results 
in a large number of cases. Thus, diagnosis is chiefly derived from se- 
meiology, and the results of clinical experience, arranged by pathology 
and statistics. In some instances, the causes and the treatment of dis- 
ease give aid in the diagnosis. Thus the malarious character of a pa- 
tient's residence, and the efficacy of quinine in curing him, will contribute 
important evidence as to the nature of his disease. 

612. Diagnosis may be general or special. General diagnosis compre- 
hends the distinction between the principles or elements of disease (§ 104) ; 
as, for example, between congestion and inflammation ; between nervous 
irritation and structural disease, &c. Special diagnosis relates to the 
distinction of diseases according to their chief seat, where they have one 
(§ 599), or according to some other specific difference, where they have 
no particular head-quarters. Thus the special diagnosis of inflammations 
is between inflammation of the parenchyma of an organ and that of its 
investing membrane ; or between an intermittent and a continued fever. 
Special diagnosis also follows and distinguishes diseases in their further 
differences of seat or character; as the part or extent of a parenchyma 
or membrane inflamed, the type of a fever, &c. Thus special diagnosis 
is a branch of special pathology, and should be aided by an accurate 
and practical nosological arrangement. The mode of distinguishing be- 
tween two diseases which resemble each other has been absurdly called 
differential diagnosis. It consists in pointing out the signs which are 
essential to the one and not to the other. The signs called pathognomo- 
nic, where they exist, are the chief guides in differential diagnosis. 

613. The modes of investigating and distinguishing diseases will vary 
much in different cases, according to the class of symptoms that first 
present themselves. This may be illustrated* by the following prob- 
lems: — 

General pathology having pointed out the general nature of a disease, 
it is required to determine its precise seat. Example. In a case in which 
fever, hard pulse, buffed blood, and local pain indicate inflammation, 
the seat of the inflammation is determined by the chief seat of pain 
or uneasiness (in the chest or side), by the function most disturbed (diffi- 
cult breathing and cough), to be in the organs of respiration ; by the 
secretion proceeding from the part (rusty, viscid expectoration), and from 
the physical signs (impaired breath-sound and stroke-sound in part of 
24 



370 



DIAGNOSIS. 



the chest, with crepitant rhonchus), to be in the parenchyma of the lungs ; 
that is pneumonia. General pathology here commences the diagnosis, 
which is completed by reference to symptoms explained by physiology 
and special pathology. 

Previous history, prominent symptoms, or physical signs, having pointed 
out the seat of a disease, it is required to determine its nature. Exam- 
pie. A person suffers from severe pain at the epigastrium; the previous 
occurrence of symptoms of indigestion, and the situation of the pain, 
plainly show the disorder to be seated in the stomach: the nature of the 
disease (whether nervous or inflammatory, &c) is to be determined by 
general pathology ; guided by this, and finding an absence of symptoms 
of inflammation, no increased heat of surface, no acceleration of the pulse 
further than what the pain would cause, and no increase of the pain on 
the imbibition of warm or stimulating liquids ; and finding symptoms of 
predominate nervous properties, and the sudden attack, intense character, 
and transient duration of the pain which distinguish nervous and spas- 
modic affections, we decide that the disease is gastralgia or gastrodynia, 
and not gastritis. The diagnosis which is begun by local symptoms is 
completed by reference to the principles of pathology. 

Lastly, which is a common case, symptoms being too few or too in- 
conclusive to lead the diagnosis, both the seat and the nature of the dis- 
ease are to be determined. A person complains of general uneasiness, 
weakness, and chilliness, with various functional symptoms, but none of 
a prominent character. Clinical experience has taught the practitioner 
that such are the symptoms of incipient fever; and he proceeds to in- 
vestigate further the nature and cause of the fever. If he finds, on close 
examination of the functions and physical condition of the different or- 
gans, that one is the seat of marked inflammation, and that the fever is 
not typhoid, he judges that the fever is symptomatic of the inflammation ; 
but if signs of marked local inflammation be absent, yet the fever con- 
tinues with increasing symptoms of depression, weak frequent pulse, 
brown dry tongue, sordes on the teeth, low delirium &c, he recognizes 
typhoid fever, resulting from the influence of a morbid poison on the 
system (§ 105). 

614. Thus every department of medical knowledge is brought to bear 
on diagnosis; and in no branch is the information as well as the judg- 
ment, of the practitioner more brought to a test. Natural shrewdness 
and tact, with some general knowledge of the nature and treatment of 
disease, may sometimes enable a comparatively ignorant person to prac- 
tice medicine with an appearance of success; but such a person can 
make no hand of diagnosis ; and he wisely either evades the whole sub- 
ject or expresses his opinions in vague terms, and scrupulously avoids 
their being brought to the test of the scalpel. The well-informed prac- 
titioner, on the other hand, feels that this is the subject which requires 
the full application of his mental powers and knowledge, as well as the 
keen exercise of his powers of observation; and in proportion as his 
senses are practised in observing, his information well arranged in re- 
lation to what he observes, and his judgment matured in discriminating 
and deciding the results, so will he be successful in diagnosis, and in 
applying it to prognosis and practice. 



INVESTIGATION OF SYMPTOMS. 



371 



615. In investigating the symptoms of a case with a view to diag- 
nosis, prognosis, and treatment, the observation is first drawn to those 
which at once declare themselves in the aspect of the patient, the ex- 
pression of the countenance, the complexion, the posture, the manner 
of the movements, speech, &c. ; and these give important information to 
the observing practitioner at first sight and whilst he is interrogating the 
patient. After the first few statements of complaints, which are gene- 
rally volunteered by the patient, the questions should be directed to the 
history of the ailment, including the previous state of health and habits, 
with regard to food, clothing, occupation, residence, &c, any former ill- 
ness, the mode of the present attack, and its supposed cause, the former 
symptoms, and treatment, if any has been employed. The answers to 
these questions will direct the inquiries in the most searching manner with 
regard to the present state, and symptoms. The mode of investigating 
these will partly depend on the clue given by the answers to previous 
questions ; but the practitioner must not permit himself to be so far led 
by the patient's statements as to omit to examine the state of all the im- 
portant organs and their functions. The nervous system and its func- 
tions, (sensorial, sentient, excitomotory, and sympathetic ;) the organs of 
circulation and their functions , (pulse of heart and arteries, capillary cir- 
culation of surface and visible parts, temperature, state of veins, &c. ;) 
the organs of respiration and their functions, (breathing, cough, expecto- 
ration, voice, arterialization of the blood;) the organs of digestion and 
their functions, (tongue, appetite, digestion, &c. ;) the organs of secretion 
and excretion and their functions, (liver and intestines, kidneys, bladder, 
and the skin;) the functions of nutrition and assimilation, (to be judged 
of by the condition of the flesh and comparative weight of the subject;) 
the organs of locomotion and their functions ; the organs of generation 
and their functions; are severally to be made the subjects of inquiry and 
physical examination to such an extent as may be requisite to inform the 
practitioner of their true condition and connection with the past or pre- 
sent disease. 

The object of a complete investigation of the state of the patient is 
not merely to determine the particular disease under which the patient 
labors, but to discover what is healthy as well as what is morbid in his 
condition. The prognosis, or estimation of the amount and event of the 
disease, and the application of treatment, requires this full investigation. 
We have to consider, not merely disease in the body, but the body in dis- 
ease; and it is by losing sight of this great practical axiom, that minute 
or microscopic inquirers, who may be singularly successful in special 
diagnosis, signally fail in prognosis and in practice. 



CHAPTER VI 



PROGNOSIS — FOREKNOWLEDGE OF THE RESULTS OF DISEASE. 

616. Prognosis is that knowledge by which we are enabled to foresee 
the course, duration, and event of a disease. Like the treatment of 
disease, it may be either empirical or rational. 

Empirical prognosis is that which is founded on experience or obser- 
vation only, without regard to the nature of the disease or the reasons 
which determine the results. It consists in the observation of the good 
and bad symptoms — that is, those symptoms which have, in a great ma- 
jority of cases, been followed respectively by a good or a bad result. 
This mode of prognosticating the events of disease was the only one 
attainable in the early ages of medicine. The " prognostics" of Hip- 
pocrates chiefly consisted in the enumeration of good and bad signs; and 
the frequent truth of the distinctions which he has made on these points 
show the extent and accuracy of his observation, or of the sources from 
which his information was drawn. In a limited sense, the same faculty 
of empirical prognosis is often acquired by nurses or other non-medical 
attendants of the sick. These can often tell when a patient is getting 
better or worse, by the appearance of the countenance, the state of the 
voice, the mind, the strength, the breathing, the excretions, &c, whilst 
they may be in total ignorance of the nature of the disease and why the 
signs are good or bad. This kind of prognostic knowledge, although it 
may be useful in enabling a person to pronounce a patient better or 
worse, falls far short of that which ought to be expected of the scientific 
practitioner, who should not only have a greater number of prognostic 
symptoms within his reach, but should be able to foresee them, so as to 
anticipate, and, if possible, to influence them in a favorable manner. 

617. Rational prognosis is the estimation of the importance and tend- 
encies of a disease from a knowledge of its causes, its true nature and 
symptoms, and of the power of treatment in regard to it. Like rational 
diagnosis (§ 614), it derives its evidence from all available sources, and 
makes the best use of this evidence by analyzing it and thus determining 
its value. Thus, in the early stage of inflammation of the lung, the 
discovery of the nature and seat of the affection at once shows the pre- 
sence of a serious disease, whatever may be the state of the present 
symptoms. The practitioner in forming a rational prognosis, takes into 
account the extent of the inflammation, knowing, from experience as 
well as from reason, that this is a source of danger: he considers the 
duration of the attack, and from the signs and symptoms judges whether 
it is increasing or not. These considerations may give him some insight 



SOURCES — THE SUBJECT. 



373 



into the severity of the disease, but his prognosis is to be determined by 
further conditions. He knows, by experience and reason, that inflam- 
mation of the lungs, although always a dangerous disease, becomes 
much less so when it is at a stage and in a subject in which antiphlogis- 
tic remedies can be well borne : thus, at an early stage, in a young and 
vigorous subject, even the most extensive inflammations may be cured 
by blood-letting and other means judiciously employed ; but if the dis- 
ease has advanced far, and the function of respiration has been for some 
days impaired by it; if the subject be feeble, from infancy, or from ex- 
treme age, or from previous disease, from intemperate habits, from a 
complicating disorder, or from any other cause, the prognosis becomes 
more unfavorable, inasmuch as there is little power in the system to bear 
the appropriate remedies, or to withstand the evil effects of the disease. 

To take an example of another disease. In continued fever, certain 
symptoms have been found by experience to be of an unfavorable cha- 
racter. The pathological practitioner profits by this experience, but he 
analyzes the results and goes further. He knows that the appearance of 
petechias, congested face, and stupor, at the commencement of fever, are 
bad symptoms, but that they are so, mainly in proportion as they arise 
from the changed state of the blood induced by the depressing cause of 
the fever; and when, as it sometimes happens, these symptoms appear 
without any corresponding depression of the heart's power, as manifest 
by extreme frequency and weakness of the pulse, they are by no means 
of such unfavorable import, buf may arise from the plethora of the subject. 
Again; symptoms referable to the excito-motory system (§ 153), — such 
as subsultus, hiccup, and convulsive affections, — are generally unfavora- 
ble in continued fever; but they are so only when arising from the severe 
operation of the cause of the fever on the nervous centres; they are 
much less so when occurring in a nervous subject, in whom slight causes 
may induce them. The same remark may be made of a state of stupor, 
which would be of most serious import if dependent on fever alone; but 
it may be induced by slight fever, or other cause, in an hysterical sub- 
ject. The pathologist is prepared for these differences, and can qualify 
his prognosis accordingly. He can trace the danger of bad symptoms, 
beyond the symptoms themselves, to those interferences with vital func- 
tions which render these symptoms dangerous, and of which these symp- 
toms are not always the true exponents. 

618. As our limits do not admit of details, it must suffice to enume- 
rate the chief circumstances from which a rational nrognosis may be 
formed, with illustrative examples. These may be arranged under the 
two general heads: — 1. Those relating to the patient or subject; and 2. 
Those referring to the disease. 

619. The age of the subject. — Acute diseases are ill borne at either 
extreme of age, when the powers of reaction are less energetic to sustain 
the struggle. Hence infants and aged persons are often carried off by 
acute attacks. Acute diseases prevail more in young and middle age 
than in advanced life, in which affections tend to assume a chronic form ; 
also from w T ant of that power of reaction and resistance by which, in more 
vigorous age, morbid actions are thrown off. [In early infancy there is 
always hope, even with the most dangerous symptoms. "Venfance est 



374 



PROGNOSIS. 



Page des resurrections says Chomel. It is at this period of life, that 
the well-known adage ubi vita, ibi spes, is so applicable. In old age, on 
the contrary, acute diseases which assume a severe form almost always 
terminate fatally. In middle age, the chances are more favorable, 
and are greatest in youth and adolescence. The exceptions to this rule 
are the eruptive fevers, which are less dangerous in infancy, and certain 
organic affections, which are said to advance less rapidly in old age. — C] 

The sex of the patient. — Nervous diseases are most common and ob- 
stinate in the female sex; but they are more serious in the male sex. — 
The occurrence of the catamenia is often favorable, as their suppression 
is unfavorable in the course of the disease. Pregnancy and lactation, 
during their continuance, suspend or retard the progress of tuberculous 
disease, and other disorders of the nutrient function, and the cessation 
of these conditions may excite the disorders into fresh activity. Erup- 
tive fevers, especially small pox and scarlatina, are peculiarly fatal to 
women during and shortly after pregnancy. 

The temperament of the patient. — In the sanguine temperament, dis- 
orders are apt to be acute, or tending to a speedy termination, favorable 
or unfavorable; in the phlegmatic temperament, more chronic, and not 
uncommonly latent or obscure in their symptoms; whilst in the nervous 
temperament, the symptoms are very prominent, often exciting much 
suffering and alarm where little or no danger may exist; and they are 
likewise remarkable for their mutability. 

Previous diseases of the patient. — The same disease having occurred 
before, prevents or renders milder a subsequent attack, in the case of 
eruptive fevers, hooping-cough, &c. ; but increases the tendency and the 
danger in case of apoplexy and most structural diseases. Albuminuria 
with dropsy is more curable, when ensuing after scarlatina, than when 
after other causes ; but rheumatism after scarlatina and gonorrhoea is 
often unusually severe and intractable. After continued fevers, and 
other debilitating diseases, inflammations often assume a subacute or 
chronic form, which may escape attention, and produce serious organic 
disease. 

Present diseases of the patient. — These generally increase the severity 
or intractability of the new disorder, especially if they be structural. — 
Thus infectious disorders and fevers are peculiarly fatal in persons w T ith 
diseased heart, lungs, kidneys or brain. Yet moderate hypertrophy of 
the heart is rather a favorable circumstance in phthisis. Cutaneous and 
some other external diseases, sometimes suspend attacks of gout, gravel, 
diarrhoea, &c. Extensive emphysema of the lung supersedes tubercles 
and most other lesions of the parenchyma, whilst it renders the bronchial 
surface and liver the seat of almost constant congestion or inflammation. 
Cancer supersedes tuberculous disease, and reduces the proneness of the 
subject to inflammation. 

Previous habits of the patient. — Habitual intemperance, and excesses 
of all kinds, enhance the danger of all serious attacks and accidents. — 
Extreme privations, or over-fatiguing employments, make people liable 
to fevers, and other depressing diseases, and reduce the powers of reac- 
tion against them ; and the same remark will apply to close confinement 
and want of sleep. 



SOURCES. NATURE, ETC. OF THE DISEASE. 



375 



Condition of the patient at the time of the attack. — Extreme weakness 
or exhaustion from any cause renders persons bad subjects for most dis- 
eases. Plethora increases the intensity of inflammatory affections. Si- 
multaneous excitement of any organ, as of the brain from moral causes, 
may add a dangerous complication to continued fever. 

620. The cause of the disease. — Epidemic, endemic, and infectious 
disorders, are chiefly serious in proportion to the intensity of their cause. 
Thus the endemic of a hot climate is more dangerous than that of a cold 
climate: an infectious disorder propagated in close habitations is more 
severe, from the concentration of its cause and co-operating influences, 
than one arising from more diluted and simple infection. By knowing 
the source of the disease, some estimate may be formed of its future 
severity. 

The situation and nature of the disease. — The more important to life is 
the part attacked, and the more the disease interferes with its function, 
the more dangerous will it be. Thus the heart, the lungs, the medulla 
of the nervous system, the kidneys, and the blood, cannot be extensively 
attacked without great danger to life; and if the disease goes on to affect 
structure, as in inflammation, the danger is prolonged in proportion. In 
a few cases disease attacking an unimportant part, as the skin or an ex- 
tremity, may prove dangerous on account of its tendency to spread to 
other parts or infect the whole frame, as in the instance of cancer, gan- 
grene, inoculated poisons, hydrophobia, &c. 

The extent and progress of the disease. — The greater the extent of the 
disease, the more serious it will be in case of inflammation; but the se- 
verity of the symptoms is often not in proportion to its extent: intense 
and circumscribed inflammation causing more prominent symptoms than 
that which is extensive and diffused. The rate of the progress of disease 
most materially influences its effect on life and health. Thus the struc- 
ture of the lungs, heart, kidneys, or liver, may become diseased to a most 
extraordinary amount, without destroying life, if the advance of the lesion 
is very gradual ; whilst a third or fourth of the same mischief would prove 
fatal, if it were induced suddenly. 

621. The character of the symptoms. — This is exhibited in the details 
of each disease. Those symptoms augur favorably which show a power 
of moderate and regular reaction, and a return of the functions to their 
natural state. The removal or alleviation of the more distressing symp- 
toms of disease — the restoration of the natural appetites, and feelings, 
bodily and mental — the regaining of strength — the returning regularity 
and moderation of the pulse and other signs of equal circulation — the 
disposition to sleep tranquilly, and w r ake at the usual times — secretions 
that have been interrupted or diminished being restored, and often in in- 
creased quantity, as if from accumulation, as in the case of critical per- 
spirations, deposits in the urine, &c. (§448), — are among the chief signs 
of approaching recovery. 

622. Bad or unfavorable symptoms are those which arise from such an 
impediment of one or more of the functions more immediately concerned 
in the sustenance of life, the circulation of the blood, respiration, nutri- 
tion, and excretion. In proportion as these functions are speedily and 
considerably impaired, life is threatened, and there is an approach to its 



376 



PROGNOSIS. 



destruction, by one or other of those terminations, which are called modes 
of death. Thus there is death by syncope — cessation of the circulation; 
by asphyxia, or apncea — interruption of the respiration ; and by inanition. 
To these maybe added, death by the pernicious influence of excrement- 
itious matters, and by poisons, which cause death in various modes. 
These different modes of death are most distinct when induced so speedily 
as to leave the functions, which they do not directly affect, comparatively 
vigorous and outliving that which has been chiefly injured. Thus, in 
sudden death from causes stopping the respiration, the heart continues to 
act for some time, until the death which has begun with the breathing 
function reaches it also. 

623. If we further trace the operation of these different modes of death, 
w 7 e shall find that they all agree in affecting the blood, either by altering 
its composition, or by arresting its circulation; and it is through one of 
these means that death extends to all the functions. Thus in death by 
cessation of the heart's action, the circulation is at once arrested; hence 
this is the most speedy mode of death. Inanition obviously operates by 
reducing the circulating material, and by further weakening the organs 
by which the circulation is carried on. Asphyxia we have already found 
(§ 235) both to impede the circulation and to alter the condition of the 
blood. Excrementitious matter retained in the blood, and extraneous 
poisons, also operate in various ways: by impairing the irritability of the 
heart; or by injuring the medullary nervous function (§ 154), on which 
respiration depends; or by arresting the passage of the blood through the 
capillaries (§ 298); or (and this probably includes some of the former 
modes), by so changing the properties of the blood itself, as to render it 
unfit for its office of sustaining the activity of the functions; and the 
operation of all poisons, as well as of other causes of death, may thus 
be traced to defective circulation or composition of the blood. It is the 
more necessary to keep these points in recollection, because they show 
why death from disease often takes place without distinctly beginning 
with any set of functions; but all fail from want of proper blood, their 
natural support. 

624. It will be useful to mention the chief varieties of the modes of 
death above noticed, and to state their symptoms, which may become 
available as prognostic signs of the approach of death. 

Death (cessation of function) beginning at the heart | ^ 

adual=asthenia. 

■ — — beginning at the breathing apparatus=Asphyxia or apnaea. 

— — beginning at the brain=Coma. 

— — beginning at the medulla=Para]ysis. 

— — beginning in the blood=Necra?mia (vexpoj, dead; aipa, blood). 

625. Death by cardiac syncope, or sudden cessation of the heart's 
action, may occur in two ways — 1. By this muscle losing its irritability 
(§ 116), so that it ceases to contract; and 2. By its being affected with 
tonic spasm (§ 114), in which it remains rigidly contracted, losing its 
usual alternation of relaxation. In both these cases, death is quite in- 
stantaneous: the subject suddenly turning pale, falling back or dropping 
down, and expiring with one gasp. In the first case, both sides of the 
heart are found, after death, distended with blood ; and if the examination 



MODES OF DEATH — BY SYNCOPE. 



377 



were made soon after death, the blood in the left cavities would be found 
to be florid. In the second case, the heart appears small and very hard ; 
the ventricles (or at least the left) are found so firmly contracted, that 
the cavity is almost obliterated, and contains no blood ; the muscle is 
very firm ; but after maceration in water, or even without it, in two or 
three days, the walls of the ventricles yield to the pressure of the fingers, 
and the cavities may be restored to their normal dimensions. This 
state of the heart was long mistaken for concentric hypertrophy, until 
Cruveilhier and Dr. G. Budd pointed out its true nature. 

Although syncope by loss of irritability (paralysis) and syncope by 
spasm, appear to be opposite states, yet they arise from somewhat similar 
causes. In animals, wounds of the heart are followed sometimes by the 
one, sometimes by the other. Death by shock, as from tearing off a limb, 
a violent blow on the epigastrium, crushing the brain or spinal marrow, 
is sometimes caused by spasm, although more frequently by paralysis of 
the heart. In sudden death from drinking a quantity of raw T spirits 
or of very cold water when the body is heated, the heart has been found 
contracted. 

Syncope by loss of irritability of the heart is the more common case; 
and, besides, in the examples above given, it may be induced by the ope- 
ration of large doses of certain poisons called sedative — such as the upas 
antiar, infusion of tobacco, aconite, and digitalis; and in combination 
with other effects, by large doses of hydrocyanic acid, strychnia, oxalic 
acid, arsenic, preparations of baryta, and various animal poisons. Mr. 
Blake found the power of the heart destroyed by solutions of various 
saline matters injected into the veins, especially salts of potass, magne- 
sia, zinc, copper, lime, baryta, and lead; but these results do not cor- 
respond w 7 ith what we find of the operation of these substances when 
introduced into the stomach. 

The diseases in which death by cardiac syncope sometimes takes 
place are — those of the heart, (but more rarely than is commonly sup- 
posed ;) hemorrhagic apoplexy, attended with much injury to the substance 
of the brain (§ 364); ana3mia(§ 270); and adynamic fevers (§ 105). 
As it occurs suddenly, there can scarcely be said to be symptoms; but 
sometimes an approach to it has been manifested in previous attacks of 
common syncope or faintness, in w T hich the action of the heart becomes 
weak, irregular, and intermittent; and the partial failure of the circula- 
tion is evinced in the paleness of the face, lips, and general surface, often 
with cold perspiration; the failure of the sensorial functions, (defectio 
animi,) loss of consciousness and volition more or less complete, some- 
times attended with various convulsive movements (§§ 153, 265); the 
eyes turning up or becoming fixed or glazed, and the pupils dilated. 
The different effects of posture on the forms of syncope have been before 
noticed (§ 70) ; and they may be presented in cases in which cardiac 
syncope ultimately proves fatal. The recovery from this faintness is 
often attended with shivering, vomiting, sighing, gasping, yawning, and 
various distressing sensations of noises in the head, flashes in the eyes, 
palpitation, depression of spirits, &c. ; whilst the pulse regains its strength 
and regularity, and the color and warmth return to the surface. After 



378 



PROGNOSIS. 



this may ensue a reaction, like that which occurs after great losses of 
blood (§§ 266, 362). 

626. Death by the gradual cessation of the hearVs action has been 
termed asthenia, (a, not, cdsvou strength.) This is the mode of termina- 
tion of many diseases, especially those which destroy life by exhausting 
the strength, without any direct interference with the more vital functions. 
Thus long-continued fevers, delirium tremens, gastritis, enteritis, perito- 
nitis, sometimes tetanus, hydrophobia, and inflammation of the brain, — 
hemorrhages, and various discharges of animal fluids — such as diarrhoea, 
diabetes, extensive ulcers or abscesses, &c, proving gradually fatal — 
inanition from want of sufficient food, and several others, — reduce the 
power of the heart, and with it the functions of the whole body, to a 
lower and lower state, until at length the heart flutters, and dies. 

The symptoms of the approach of death by asthenia are — increasing 
weakness of body and mind, whilst there maybe no marked derangement 
of any particular function of either; increased frequency, and diminish- 
ing strength of the pulse; the face, lips, and other parts of the surface, 
gradually become paler and paler, or of a death-like sallowness; the 
extremities lose their warmth, and often become (Edematous; the appetite 
fails ; the tongue becomes sometimes dry and brown, sometimes furred, and 
the mouth aphthous (§ 483); the excretions first are imperfectly voided; 
then the sphincters lose their power, (the weakness reaching their excito- 
motory function,) and involuntary discharges of urine and feces may take 
place ; and this state of sinking in a few hours terminates in death. The 
symptoms above described are those of progressive loss of power, not 
confined to the heart, but through its failure and that of the circulation 
of the blood, of which it is the chief instrument, becoming extended 
throughout the whole frame. But with this general debility there are 
often symptoms of partial excitement and reaction, which sometimes 
mark the sinking state. Thus a febrile excitement of a hectic kind 
(§ 471) may come on, giving slight temporary strength to the pulse, 
flush to the cheek, life to the eye, and a sort of flickering reanimation to 
the whole frame. Sometimes the excitement is more partial, affecting 
the brain, as with delirium ; or the medulla, as with subsultus tendinum, 
hiccup, or other slight convulsion; or the stomach, as with vomiting, 
&c. Or in the sinking state, some functions may become obscured be- 
fore others, in consequence of congestions, effusions, or even low inflam- 
mations occurring in the capillaries of some organs (§ 290), as the 
powers of the general circulation fail : thus the death by asthenia may 
become somewhat complicated with coma from congestion or effusion 
within the head; or with dyspnoea from congestion in the lungs; or some- 
what similar symptoms may arise from the early failure of the excreting 
organs, and the retention of excrementitious matter in the blood (§ 249). 

627. Asphyxia or apncea has already been noticed as an element of 
disease (§ 234), and its nature and symptoms were then examined 
(§ 235); we here advert to it as a mode of death. By death beginning 
at the breathing apparatus, I mean that in which the function of this 
apparatus is the first to fail. In this respect it is distinguished from 
death beginning at the brain or medulla, which destroys by secondarily 



MODES OF DEATH — BY APNCEA. 



379 



suspending the function of breathing, and the distinction is useful for 
practical purposes as serving to direct attention to the most suffering 
organ. Death by simple apncea takes place in diseases of the lungs and 
air-tubes, in which the entrance of air to the lungs is impeded by effusion 
into the air-cells or tubes; or by pressure upon them, as in bronchitis, 
pneumonia, pleurisy, &c. ; by obstruction to the passage of the air through 
the trachea or larynx, as in croup, laryngitis, and tumors or spasm con- 
stricting these tubes; or in circumstances mechanically excluding the 
passage of air by the mouth and nostrils, as in smothering, strangling, 
hanging, and drowning. 

The symptoms of the approach of this mode of death are — increasing 
feeling of suffocation or want of breath, which becomes most distress- 
ing and agonizing as the want is unappeased; the efforts at respiration 
are made in a hurried and forced manner; the face, neck, and other 
parts of the surface become congested in proportion to the violence of 
these efforts ; and as these efforts are unsuccessful, the color of the con- 
gested parts changes from red to purple, and from purple to livid. The 
influence of this congestion and partial circulation of black blood ( § 235), 
is soon'evidenfon the functions, causing stupor, reduction of temperature, 
weak and irregular pulse, rapid reduction of muscular strength, and 
consequently of the efforts to breathe. Hence the dark hue of the face 
may be changed to paleness; but the lividity of the lips, tongue, nails, 
and other colored parts, remains until death. In cases of speedy death 
from violence, as hanging, drowning, &c, or from a sudden attack of 
laryngitis or spasm, the respiratory efforts are more vigorous, and the 
congestion and lividity of the surface are greater, and may remain until 
death. But in the slower asphyxia from diseases of the lungs and air- 
tubes, the interruption to the breathing is less complete, the efforts are 
less violent, the congestion of the surface is less marked, and the func- 
tions more gradually failing together, the symptoms peculiar to apnoea 
are less decided. Hence, too, as imperfectly arterialized blood is cir- 
culated throughout the body, it may cause peculiar symptoms, such as 
stupor and low delirium, partial paralysis, vomiting, relaxation of the 
sphincters, and other symptoms of sinking. This exemplifies what has 
been before remarked (§ 622), that the distinctness of each mode of death 
generally depends on its speedy supervention. 

As prognostic signs, the symptoms of apncea are more hopeless in 
proportion as they are conjoined with those of debility. The nature of 
the obstruction to the respiration must of necessity be taken into account; 
and if this be not complete and irremovable, the congestion and lividity 
of the surface are not fatal signs, so long as the strength of the breath- 
ing apparatus and of the heart does not decline; as this becomes ex- 
hausted, the means of recovery are lost. 

628. Death by coma, or beginning at the brain, is caused by various 
influences which primarily destroy the functions of the superior masses of 
the nervous system. The chief of these circumstances are obstruction 
to the circulation through the brain by pressure, (as of effused blood, 
pus, lymph, or serum, or of distended vessels in apoplexy, a depressed 
portion of bone in fractured skull, &c. ;) by coagula within the vessels 
in anaemia (§ 267); and by various narcotic poisons, such as opium, 



380 



PROGNOSIS. 



alcohol in large quantities, carbonic acid or ether vapor inhaled (§§ 128, 
246), and sometimes the excrementitious matter of urine and of bile in 
the blood (§ 249). 

The symptoms of coma are those of interrupted function of the brain, 
insensibility and suspension of voluntary motion, the heart's action not 
being materially impaired. These may come on in different modes. In 
apoplexy and injuries of the head they may supervene suddenly, and the 
patient at once becomes powerless and senseless, the pulse continues 
pretty good, although slower and fuller than usual, or it maybe frequent 
from mere sympathy. In other cases, the stupor comes on gradually, 
and the senses and mental powers are often irregularly obscured, causing 
dimness of sight, appearances of clouds or cobwebs before the eyes, 
muscce volitantes: various imperfections of hearing, with noises, or tinni- 
tus aurium; numbness and tingling sensations in the limbs; loss of 
memory, confusion of ideas, hallucinations, low delirium alternated with 
stupor (typhomania), continued somnolency, &c. Partial paralysis often 
accompanies progressively advancing coma, sometimes of the lower ex- 
tremities (paraplegia), more commonly of one side (hemiplegia). In the 
operation of narcotics, the state of coma is commonly preceded by symp- 
toms of cerebral excitement, manifest in the usual signs of intoxication 
and delirium, which vary in the case of different poisons. For these 
particulars, I must refer to works on toxicology and materia medica. 

In conjunction with these symptoms, referable to the sensorial and 
voluntary functions, there are often symptoms of various affections of the 
excitomotory system of the medulla; at first they are those of excitement, 
such as convulsion, vomiting, hiccup, contracted pupil, &c. (§ 152). 
Thus, the coma of apoplexy, and sometimes the stupor of narcotism, are 
occasionally accompanied by convulsions (§ 150), general or local; and 
I have elsewhere (§ 153) endeavored to explain how these opposite effects 
on different parts of the nervous centres may arise from the same cause. 
But in cases of more extreme coma, the excitomotory power of involun- 
tary motions becomes impaired, the breathing is stertorous and imperfect, 
the actions of coughing and expectoration are not easily excited, deglu- 
tition becomes impossible, the pupils are dilated, emetics fail to excite 
vomiting, the sphincters are relaxed, and involuntary discharges of urine 
and feces take place. The last group of symptoms was before noticed 
as the fatal part of coma and narcotism (§ 154). 

It is a question whether the functions of the brain can be completely 
suspended for any length of time wuthout those of the medulla suffering 
also. During common sleep there is not complete insensibility or sus- 
pension of volition, for movements are then made in consequence of un- 
pleasant sensations, yet without the sleep being broken. It is probable 
that in the trance of nervous subjects, of hysteric coma (141), neither 
sensation nor volition is entirely abolished ; but it is difficult to ascertain 
the truth in these cases, for the patients often deceive themselves as well 
as others. But in the heavy sleep of intoxication, and in the stupor of 
coma, in which pinching scarcely excites any evidence of consciousness, 
the functions of the medulla seem to be also impaired, for the breathing 
is slow and stertorous, and irritations of the nose and eyes less readily 
than usual excite the motions of sneezing and winking. It is in pro- 



MODES OF DEATH — BY COMA. 



381 



portion as these functions are impaired that coma becomes dangerous ; 
and it is because they are not impaired (and in some instances are 
distinctly augmented as manifest by the sighing and spasmodic twitching 
that occur) in nervous or hysteric stupor, that this is unattended with 
danger. It appears probable, however, that coma, when complete, may 
cause death by the abolition of sensation only, and if so, we are war- 
ranted in distinguishing between death by coma and death by paralysis 
of the medulla. Although the movements of breathing are ordinarily 
independent of the consciousness or will, yet such is not the case of the 
extraordinary movements which commonly take place in a deep breath 
or sighing; when the ordinary action is impeded by posture, fatigue, ex- 
haustion, or any other debilitating cause. Under these circumstances, 
when the function of the brain is unimpaired, the feeling of want of 
breath arouses a succession of voluntary efforts, which are manifest in 
suspirious breathing, and which are the cause of sleeplessness in deli- 
rium tremens, and other states of exhaustion (§ 154). But when sensi- 
bility and voluntary power are wholly suspended, these supplementary 
efforts are not made; for want of them, the respiration is insuffi- 
ciently performed, and the lungs and air-tubes gradually become con- 
gested ; this congestion and the resulting secretion further impair the 
involuntary part of the process of respiration, and thus without any in- 
dications of paralysis of the medulla, the signs and effects of apncea are 
slowly superinduced on the state of coma. Under such circumstances, 
it is of great importance to place the patient in such postures or other 
circumstances, as shall most favor the movements of breathing, and 
remove pulmonary congestion by the proper remedies, should it arise. 

Snoring arises from a relaxed state of the soft palate, and is of little 
moment so long as the movements of breathing are sufficiently strong 
and frequent ; but when the respiratory powers are impaired, stertor is 
not only a sign but a cause of obstruction to the passage of the air, and 
should be prevented as much as possible by changing the posture of the 
patient. 

The most dangerous kinds of coma, then, are those attended with 
symptoms of impaired excitomotory function, or those so profound and 
prolonged, as to deprive the respiration of all aid from voluntary efforts, 
the signs of danger being apparent especially in connection with the 
respiration. In apoplexy, contraction of the pupil of one or both eyes 
is of very unfavorable import, because it indicates an excitement of the 
upper portion of the medulla, whilst the brain is oppressed: such a com- 
bination can only proceed from the partial operation of a clot in the 
substance of nervous centres, compressing one part and irritating another. 

629. That death should ensue from injured function of the medulla 
oblongata and spinalis is quite intelligible, when it is considered that on 
this portion of the nervous system the ordinary act of breathing depends. 
This mode of death, like the last, is by apncea; but the death, or failure 
of function, here begins with the nervous link of the chain of actions con- 
stituting the process of respiration; Avhereas in simple apncea, it com- 
mences with the mechanism of the breathing apparatus. 

This death may be called death by paralysis, and, as in other cases 



382 



PROGNOSIS. 



of paralysis of the excitomotory function (§ 144), it may be caused by 
suspended function, either of the nervous centre (medulla oblongata), 
or of the afferent nerves (parvagum and sympathetic), or of the efferent 
nerves (phrenic, intercostals, and spinal accessory), which complete the 
respiratory circle. Of influences which destroy the function of the me- 
dulla oblongata itself, may be mentioned, hemorrhagic effusion into its 
substance or upon it, fractures of the base of the skull, and any very 
considerable pressure on the whole encephalon. I have witnessed se- 
veral deaths from encephalic hemorrhage, in which the stroke was not 
attended with loss of consciousness, and would not therefore be termed 
apoplectic, but paralytic, with loss of power of articulation, hemiplegia, 
and laborious and stertorous breathing, which was obviously aided by 
voluntary efforts or struggles, the patient by gesticulations, and violent 
gaspings, showing his consciousness of the failing respiration. In two 
such cases, in addition to some hemorrhage in one hemisphere of the 
brain, there was a clot in the pons Varolii. These cases establish the 
truth of the distinction between the death by coma and death by paralysis. 
Some poisons also seem to affect the medulla more immediately than the 
brain. Thus, animals poisoned with w^oorara, essential oil of bitter 
almonds, conia, belladonna, and perhaps some other poisons, are affected 
with gaspings and other signs of impared function of respiration before 
they lose consciousness; according to the experiments of Sir B. Brodie 
and others, they die simply from suspension of respiration, and if this 
process be artificially maintained for a time, the animals may sometimes 
recover from the effects of the poison. The same remark in some degree 
applies to opium and its active principle, but less distinctly, for these 
early induce coma, and often impair the action of the heart also. Expe- 
riments are wanting to establish the elementary operation of this and 
other poisons, as the functions are now viewed by physiologists. In 
some cases in which I have seen animals die from rapid hemorrhage, the 
respiration has ceased for some seconds before the heart's action ; and 
from the peculiarly labored state of the breathing, and late retention of 
consciousness, I conclude, that death from hemorrhage, in some instances 
at least, is due to suspension of the function of the medulla. 

630. The division of the eighth nerves in the neck in animals illus- 
trates one mode of inducing death by paralysis. These are the chief 
incident or afferent nerves from the lungs to the medulla, transmitting 
the impressions which excite the motory nerves of the muscles of respi- 
ration. When they are divided, the breathing is imperfectly performed, 
and expectoration and cough cannot take place; apnoea, therefore, gra- 
dually follows. Although we have not a result to the same amount ex- 
hibited in disease, yet we have an approach to it in the dyspnoea, some- 
times constant, sometimes in paroxysms, caused by pressure of tumors 
on these nerves, or by malignant disease involving them. 

631. The third mode in which the nervous link of respiration may be 
broken by injury to the excitomotory column of the spinal marrow or its 
branches, is exemplified in the case of breaking the neck, or dislocation 
of the upper cervical vertebrae. Pithing an animal effects the same 
thing. All parts supplied by nerves from below the injured portion of 
the medulla become paralyzed, and therefore their motions cease. Dis- 



MODES OF DEATH — BY PARALYSIS. 



383 



eases in the vertebrae, in the spinal cord, or in its membranes, have been 
followed by similar results; and the functions of the several nerves of 
respiration are illustrated by these cases. I have known disease affect- 
ing the cord at the upper cervical vertebrae cause loss of motion in all 
parts below the neck except the diaphragm, which is supplied by the 
phrenic nerve, and through which for awhile respiration was wholly 
carried on. The patient afterwards regained power in the spinal acces- 
sory nerve, by which he was enabled to elevate the upper part of the 
chest; and subsequently some power was for a time restored to the supe- 
rior intercostal nerves and muscles.* In other cases, disease of the spinal 
cord creeps from below upwards, beginning with paralysis of the lower 
extremities and pelvis, then reaching the dorsal spine, palsying the inter- 
costals, and at last reaching the neck. The advance or retrogression 
of all these symptoms are of great importance in the prognosis of such 
diseases. 

632. Besides the respiratory functions, the functions connected with 
excretion are dependent on the integrity of the spinal cord ; they fail 
when it is seriously injured, and this failure may furnish symptoms of 
death, beginning at the spinal cord. When the cord is injured only at 
a point, and remains healthy above and below it, the injury may merely 
intercept the transmission of sensation upwards, or of volition downwards, 
beyond the injured point. Hence, there may be loss of sensation, or of 
voluntary motion, or of both, in the lower portions of the body. If this 
reach the urinary apparatus, the power of spontaneously voiding urine 
is lost. But the reflex or independent excitomotory influence of the 
spinal cord remains; hence, the sphincters and the bladder retain their 
power, and when the catheter is introduced into the bladder, it contracts 
as usual, aided by the voluntary power remaining in the diaphragm and 
abdominal muscles. We have before noticed (§ 149), that under these 
circumstances the muscles of the lower extremities retain and accumu- 
late their irritability, and although the will has no command over them, 
yet tickling, or even touching them, may excite them to contract with 
unwonted energy (§ 141). The exercise thus kept up seems to be suffi- 
cient to preserve their nutrition, for they do not w T aste away. 

But it is quite different if the spinal cord be extensively injured, as by 
crushing, softening, or a considerable effusion of blood or pus into its 
sheath. Its function then ceases, not only as a communicator of sen- 
sation and voluntary power to the lower parts of the body, but also as a 
source of that involuntary excitomotory power by which the sphincters 
contract and the urinary bladder evacuates its contents. Hence, there 
is constant dribbling of urine, yet without the power completely to empty 
the bladder. The faeces are discharged unconsciously, and without the 
power of control. The limbs are not only insensible and powerless to the 
will, but their muscles can no longer be excited by tickling: they lose 
all motion, and the blood-vessels lose that influence which the nerves of 
all orders exercise upon them. It is not surprising, under such circum- 
stances, that the death which has begun in the spinal cord should spread 
to the parts whose functions it can no longer maintain. The urine, 



* Med. Chir. Trans. 1843. 



484 PROGNOSIS. 

imperfectly discharged, putrefies, and causes inflammation of the bladder, 
which may gradually extend to and stop the function of the kidneys. 
The intestines become distended and obstructed with gas and pent-up 
faeces. The limbs lose their proper circulation for want of motion and 
nervous influence in their muscles and vessels; their nutrition fails, they 
become oedematous, partially inflamed, livid, and run into gangrene; 
and all these changes are so many signs of the progress of death which 
has begun in the spinal cord. 

From the remarkable effect of cold and some poisons on some of the 
lower animals, inducing paralysis of the hinder extremities, it is probable 
that these agents are capable of especially injuring the function of the 
spinal cord, beginning with the remote part. Has the gangrene of the 
lower extremities, sometimes induced by the use of ergotted corn, any 
connection with an injured function of the spinal cord? 

Death of the medulla supervenes on that beginning with coma and 
asthenia in many cases; and as its involuntary excitomotory function is 
the guardian of many processes essential to life, the symptoms connected 
with it are of great importance in connection with prognosis. (See § 154.) 

633. Necrcemia, or death beginning with the Mood, are terms which 
I venture to give to those fatal cases in which the chief and most re- 
markable change is exhibited by the blood. In typhoid fevers and others 
of the malignant or pestilential kind (§ 105), none of the solids of the 
body constantly exhibit such an early change of function or of structures 
as would w T arrant us in tracing disease and death to them. It is true, 
that the functions of many solids are impaired — the muscular and nervous 
systems, secretion, digestion, assimilation, and nutrition, all suffer, but 
the very universality of the affection seems itself to point to some cause 
more general than can be found in any individual function; and such a 
cause maybe found in the blood. The blood, at an early period of these 
diseases, when they occur in their worst form, exhibits changes which 
show that disorder begins with it, and this disorder may reach to a fatal 
degree. The appearance of petechias and vibices on the external sur- 
face, the occurrence of more extensive hemorrhages in internal parts, 
the general fluidity of the blood (§ 196), and frequently its unusually 
dark or otherwise altered aspect (§ 186), its poisonous properties as ex- 
hibited in its deleterious operation on other animals (§ 259), and its 
proneness to pass into decomposition, point out the blood as the first seat 
of disorder, and by the failure of its natural properties and functions as the 
vivifier of all structure and function (§§ 182, 263), it is plainly the 
medium by which death begins in the body. How far the change in the 
blood is in its structure (§ 189) and vital properties (§ 211), or in its 
chemical composition (§ 181), further research alone can determine; the 
vivifying function of the blood depends on all these combined, and it is 
this function w T hich obviously fails. Hence, the complete adynamia, or 
general prostration of all living powers, which occurs where this cause of 
death is most powerful. The blood, the natural source of life to the 
whole body, is itself dead, and spreads death instead of life. Almost 
simultaneously, the heart loses its power, the pulse becoming very weak, 
frequent, and unsteady; the vessels lose their tone, especially the capil- 



MODES OF DEATH — BY NECRJEMIA. 



385 



laries of the most vascular organs, and congestions occur to a great 
amount (§§ 290, 293); the brain becomes inactive, and stupor ensues; 
the medulla is torpid, and the powers of respiration and excretion are 
imperfect ; voluntary motion is almost suspended ; secretions fail; mole- 
cular nutrition ceases ; and at a rate much more early than in other modes 
of death, molecular death follows close on somatic death — that is, struc- 
tures die and begin to run into decomposition as soon as the pulse and 
breath have ceased ; nay, a partial change of this kind may even precede 
the death of the whole body (somatic death — Dr. Pritchard*) ; and the foetid 
aphthous patches in the throat, the offensive colliquative diarrhoea of per- 
sons in the last stage of various fatal diseases ; parts running into gangrene, 
as in the carbuncle of plague, the sphacelous throat of malignant scarla- 
tina, and the sloughy sores of the worst forms of typhus, and in the large 
intestines in dysentery, and the putrid odor exhaled even before deathf 
by the bodies of those who are the victims of similar pestilential dis- 
eases — are so many proofs of the early triumph of dead over vital 
chemistry. 

634. We have hitherto represented an extreme case; but there are 
many lower degrees in which disease begins with the blood, and various 
disturbances and reactions result. The causes which appear thus pri- 
marily to affect the blood are especially endemic, epidemic, and infec- 
tious influences, called poisons (§§ 81, 88, 93), certain animal and 
vegetable poisons, as that of the most venomous reptiles and fungi, and 
probably some mineral poisons, as sulphuretted hydrogen, selenium, and, 
in part of its operation, arsenic. The direct influence of all these agents 
is depressing (§ 105), and when they operate in large quantities, or in a 
concentrated form, the vital powers fall quickly into a state of adynamia 
or prostration, which soon ends in death, as we have already described 
it, the blood first and most constantly manifesting a change. But if the 
noxious influence is in smaller quantity, or more diluted, the vital powers 
react against it (§ 16) in various ways, the object of which can often be 
plainly discerned to be its expulsion from the system. The shivering, 
hot stage, and sweating termination, of paroxysms of intermittent fever; 
the similar but less marked series of febrile movement which occur in 
slight forms of remittent and continued fevers ; the profuse and violent 
fluxes from the stomach and intestines in cholera, dysentery, and epi- 
demic diarrhoea, and the similar discharges induced by poisonous ingesta, 
are instances of the operation of vital reaction attempting the expulsion of 
the noxious matter, and of that part of the animal fluids that had been 

* See Dr. Symond's interesting essay on " Death,*' in the Cyclopaedia of Anatomy and 
Physiology. 

"j* Certain anecdotes, usually considered to be superstitious, derive some probability from 
the above mentioned facts. It is said that some of the lower animals, especially dogs and 
rats, have an instinctive foreknowledge of the approach of death in a house. I have known 
two instances, in which for two days before a death and until the body was removed from 
the house, rats from the drains infested the basement of the house in a degree never ap- 
proached before or since. It is possible that a deathy odor (of which some sensitive persons 
profess themselves conscious) may be perceptible to the acute olfactory organs of these ani- 
mals; or perhaps a more substantial cause of attraction may be presented in the putrid ex- 
crementitious discharges thrown down the drains under these circumstances; and this notion 
may give some countenance to the still more marvellous assertions generally made by sailors, 
that sharks will pertinaciously follow a ship that bears a dying man or corpse. 

25 



386 



PROGNOSIS. 



corrupted by it. But these struggles in many instances constitute serious 
diseases, in which life maybe compromised by the violence and exhaust- 
ing effect of the reaction as much as by the prostrating influence of the 
cause of the disease: in these more complex affections, individual organs 
may especially suffer in different cases, and the danger and cause of 
death maybe less in the changed condition of the blood than in the affec- 
tions of particular organs, or the exhaustion consequent upon them, 
which destroy, not by necrsemia, but by coma, asphyxia, or asthenia, 
modes of death already considered. 

635. The injurious effect of these poisons may be still more completely 
prevented when their quantity is small and the living powers are vigor- 
ous. A diarrhoea, a profuse sweat, or a free flow of urine, sometimes 
carries off the commencing disease. The intestines, the skin, and the 
kidneys, appear to be the proper emunctories through which morbid 
matter is expelled. The peculiar fetor of the secretions from the bowels 
in typhoid fever, the beneficial influence of moderate diarrhoea, which 
removes them in the early stage of fever, and appearance of a foul fibrin- 
ous matter (typhus-material of German writers), in the intestinal glands, 
seem to be examples of the elimination of a morbific matter; and I have 
before suggested (§ 404, note), that the follicular inflammation, ulceration, 
and sloughing of the intestines in fever may arise from the excessive irri- 
tation of the follicles in the exercise of this eliminating function. Again, 
with regard to the kidneys, it has been before mentioned, that granular 
degeneration, which impairs their function and power of elimination, 
renders the body peculiarly liable to contract epidemic and infectious 
diseases, and to succumb under them(§ 260).* This renders the prog- 
nosis unusually unfavorable in these cases. The same remark extends 
and for the same reasons, to persons who have been habitually intempe- 
rate. On the other hand, those whose kidneys are naturally active, more 
effectually resist disease, and more readily throw off its effects (§ 448). 
In like manner, it is well known that persons with a naturally dry skin 
do not so readily get rid of a fever as those in whom perspiration is readily 
excited. 

636. Besides the influences already mentioned (§ 634), as first attack- 
ing the blood, and in extreme cases injuring its composition and causing 
it's death, there are others originating in the body itself. Thus the pro- 
cesses of gangrene and suppuration sometimes infect the blood with a 
septic poison (§§ 470, 475), and cause death in a manner and with symp- 
toms like those of the poisons above noticed. The sudden suppression 
of the excretions of urine or bile, from disease, or under the influence of 
any severe shock, also seem in some cases to operate by injuring the pro- 
perties of the blood; whilst in other instances it distinctly induces coma 
or asthenia. We have before adverted to retention of excrementitious 
matter as a cause of cachcemia, or depraved state of the blood (§§ 249, 

* This was exemplified in the case of an epidemic erysipelatous angina, which attacked 
several patients of the University College Hospital, in the spring of 1843. Out of about a 
dozen cases in which persons affected with various diseases were attacked, three died from 
the erysipelas extending to the larynx, and in all these the kidneys were granular and the 
urine albuminous. 



MODES OF DEATH — BY NECRiEMIA. 



387 



564) ; so we now find that, in an extreme degree, it may cause necrcemia, 
or death of the blood. 

637. The symptoms which should make us apprehend the approach 
of death by necraemia may be gathered from the preceding descriptions. 
Those symptoms generally called typhoid, putrid, or malignant, belong 
especially to this class of deadly influences. For example: a congested 
appearance of the whole surface, the color being dusky or livid, and ex- 
tending to the conjunctiva, tongue, and fauces; various slight exanthe 
matous or papular patches on the skin, often with petechia ; more exten- 
sive hemorrhages in form of ecchymoses, or oozing of thin bloody fluid 
from the gums, nostrils, and sometimes from other passages; extreme 
prostration of strength, with an obtuse state of all the senses and mental 
faculties, sometimes combined with delirium and twitchings of the limbs ; 
half-closed eyes and dilated pupils ; a very frequent, weak, and soft pulse ; 
frequent and unequal respiration ; no appetite ; intense thirst, a dry, brown 
tongue, with dark sordes on the lips and teeth; a progressive fall of tem- 
perature, w T hich may have been elevated at first ; often cold, clammy, 
and fetid perspiration; hiccup; subsultus tendinum ; scanty, offensive 
urine; involuntary discharges. 

Some diseases of the same class are modified by peculiar effects. Thus 
in malignant cholera, excessive discharges of serum, by vomiting and by 
stool, reduce the blood to such a spissitude, that it will no longer circulate 
through the vessels; the pulse ceases, and the surface becomes blue and 
cold from the darkness and stagnation of the blood, and shrunk from the 
exhaustion of its fluids. In yellow fever, altered blood is ejected from 
the stomach in the form of what is called black vomit. But to pursue 
this subject into further details belongs rather to the department of special 
pathology. 

638 It has been before mentioned, that the complete distinction of 
these different modes of death is almost exclusively confined to cases of 
speedy or sudden death. In the slower dissolution, by which diseases 
generally prove fatal, all functions and structures are more or less in- 
volved ; and the life in all is dwindled down to so slight a thread, that 
when it breaks in one, others scarcely retain it long enough to enable us 
to say that death begins distinctly in any part. 

[A brief sketch of some of the most common symptoms influencing 
our prognosis, will not, perhaps, be here without value. 

Much may be inferred from the general aspect of the patient. Con- 
stant change of position, unimportant in the beginning of acute diseases, 
becomes alarming when it persists for any time. Lying continually in 
the same position, as constant dorsal decubitus, in low forms of disease, 
is a very bad symptom. Inability to lie down, which sometimes happens 
in thoracic disease, is equally sinister. Jactitation succeeding to quietude, 
in the latter stage of acute disorders, is generally a mortal sign, espe- 
cially when accompanied by an attempt to throw aside the bed-clothes, 
and ineffectual efforts to rise. 

Progressive emaciation in acute affections is of little importance, but 
in chronic disorders it should lead us to anticipate a fatal termination in 
proportion to its rapidity. General oedema is of extremely bad augury. 



388 



PROGNOSIS. 



The occurrence of sloughs in various parts of the body, in both chronic 
and acute disorders, is a very bad sign. The physiognomy should be 
especially studied in reference to prognosis. When the natural expression 
of the countenance is preserved, it is always of favorable import. Great 
alteration in the features in the commencement of an acute disorder, 
ought to make us fear, about the fifth or ninth day, the supervention of 
low symptoms. In the advanced stage of all diseases, a sudden and 
great alteration in the physiognomy announces approaching dissolution. 
When it occurs at a period where a fatal termination is not to be antici- 
pated, it should lead us to suspect the development of some acute affec- 
tion, the enfeebled state of the patient not admitting of its exhibiting the 
ordinary local symptoms ; a sudden aggravation of the general symptoms 
being the only indication. It generally announces death in less than 
three days. This change of countenance must not be confounded with the 
pallor which marks the commencement of convalescence in fever, etc.; 
the accompanying phenomena serve to distinguish them. Subsultus, 
trembling, and rigidity always mark danger. Carphologia, epileptic and 
tetanic convulsions, rigidity of the limbs, are mortal signs in the ad- 
vanced stages of fever. Another invariably fatal symptom, according 
to Chomel, is the automatic movement by which the patient seeks to 
approach his hand to his body, whilst the physician is feeling his pulse. 
Aphonia is a bad sign in acute disorders. The intensity of pain, by no 
means, in general, indicates the amount of danger. Ceteris paribus, 
deep-seated pain is more unfavorable than that which is superficial; and 
that which is fixed more so than that which is variable. The sudden 
cessation of pain in inflammation, joined to great alteration in the fea- 
tures, indicates approaching death. According to Chomel, suppuration, 
not gangrene will be found, under such circumstances, on examination. 
Deafness is a sympathetic phenomenon occurring in many acute diseases, 
and is always serious. In the mortality of typhoid fever, if a comparison 
be made of those who suffered from deafness in the course of the disease 
and those who did not, the deaths among the former will be found as two 
to one among the latter. (Chomel.) Hope and cheerfulness are gene- 
rally good signs. Distrust and despair are very unfavorable symptoms. 
It is rarely that patients who have the persuasion that they will die, re- 
cover, unless they are hypochondriacs. Total indifference is a bad sign. 
In several chronic disorders, the tranquil security enjoyed by patients 
does not diminish the gravity of the prognosis. 

The prognostic signs furnished by delirium are connected with its 
intensity, persistence, and the conditions under which it occurs. Mild 
delirium, soon passing off", is not serious; permanent delirium always is. 
Many persons, of all ages, are liable to delirium whenever they are at- 
tacked with ephemeral fever, or an angina; it is only necessary to be 
aware of the idiosyncrasy in order to appreciate the value of the symp- 
tom. 

Prolonged sleep in the course of fevers is not dangerous if the patient 
be readily aroused. Coma is alarming and nearly always mortal when 
intense and permanent. 

The sudden occurrence of a voracious appetite announces speedy 
death, (Baglivi.) Chomel has frequently met with this symptom in pneu- 



PROGNOSIS. 



389 



monia ; death soon took place. Dysphagia is generally a mortal symp- 
tom in cerebral and acute disorders. 

The signs which the respiration furnishes prognosis are important and 
rarely deceive. A hurried respiration indicates great danger. When 
the number of respirations amounts to fifty in the minute, it may be 
generally stated that death will soon follow. The tracheal rattle and 
stertorous breathing are usually precursors of dissolution, especially 
when they occur towards the latter stages of cerebral disease. In in- 
flammation of the lung stertor is not alarming so long as expectoration 
takes place. Paroxysmal is less dangerous than permanent dyspnoea. 
Hiccough is a very unfavorable symptom in the latter stages of disease, 
unless it is accompanied by a notable amendment in the other symptoms. 

The pulse furnishes few but important symptoms. A pulse of mode- 
rate frequency and force is favorable. Considerable frequency of pulse 
indicates something serious. A pulse of 150 in an adult should lead to 
a very unfavorable prognosis. If at an advanced period of any affection 
the pulse becomes irregular or intermittent, or ceases, death is near. 

Augmentation of the heat of the body is of bad import, especially 
w T hen dry. Sudden chilliness of the extremities and rest of the body- 
occurs usually a short time previous to dissolution. Chills at an ad- 
vanced period of the disease, should lead to the suspicion of the form- 
ation of pus, or of its resorption, according to circumstances. Abundant 
sweating towards the close of a disease is a favorable sign. Cold 
sweats at the same period are generally unfavorable. 

Hemorrhages at the beginning indicate usually that the disorder will 
be serious. Towards the close they are either favorable or unfavorable. 
Epistaxis, the hemorrhoidal flux, and metrorrhagia, are generally favora- 
ble signs in those who are liable to them.. Hemorrhages from the lungs 
and intestines are usually mortal; those from the urinary organs nearly 
constantly fatal. 

The degree of strength w T hich the patient possesses is of great im- 
portance in forming a prognosis ; considerable diminution or perversion 
is always dangerous, especially in the early stage of the disease. — C] 



CHAPTER VII. 



PROPHYLAXIS AND HYGIENICS. 

639. Prophylaxis is the guarding against a particular disease ; and 
hygienics relate to the prevention of diseases in general, or to the pre- 
servation of health. The former is connected with special rather than 
with general pathology; and it should be founded on a due knowledge 
of the causes, nature, and tendencies of diseases, and of the various 
means in diet, regimen, residence, and medicine, which are capable of 
removing the causes of disease, or of preventing or counteracting their 
operation. 

640. Hygienics* consist in the knowledge and application of those 
means, by which the structures and functions of the body may be kept 
in that normal state which conduces to their continued welfare — that is, 
in health (§ 6). We have found, that both structures and functions have 
the elements of disease in themselves, when anything disturbs their due 
proportion. We have noticed the circumstances which lead to such 
disturbance, both in connection with the causes of disease (under the 
head Etiology), and in connection with its intimate nature (in the di- 
visioii Pathology proper) ; and remarks on the medicinal and hygienic 
means of preventing or counteracting those circumstances were intro- 
duced in the context to a sufficient extent to suggest the principles of 
hygienics. It will be sufficient in this place to consider briefly the chief 
corresponding circumstances which promote the maintenance of health, 
and these may be arranged under the following heads: — Food ; Clothing ; 
Temperature; Air ; Exercise; Mental Occupation ; Sleep and Excretion. 
The nature of this work precludes many details on these important 
topics, and the following is intended as a mere outline in conformity 
with the principles previously explained. 

[The object of hygiene is the preservation of health and the prevention 
of disease ; and hygienics include everything w 7 hich tends to accomplish 
these ends. Although hygiene has been called the medicine of healthy 
individuals, it is still applicable and even indispensable to invalids, and is 
often bf more service to them than medicine itself; for whilst the effi- 
cacy of many remedies may be doubtful, the propriety of hygienic mea- 
sures is universally admitted. By their aid alone, without a resort to 
the materia medica, the majority of acute disorders will terminate favor- 
ably; without them our best directed efforts will often prove unavailing. 



* I use this term (derived from the Greek vyutvixo;, relating to health, and analogous to 
optics, acoustics, &c.) as more conformable to our language than the French term hygiene. 



PROPHYLAXIS AND HYGIENICS. 



391 



We frequently see patients in bad hygienic conditions, perish in spite of 
able physicians, and an abundance of remedies, and the mildest dis- 
eases converted into mortal ones from similar reasons. The crowding 
of patients into narrow, ill-ventilated places, the contamination of the 
air, the absence of cleanliness, the want of suitable clothing, exposure 
to cold and wet, errors of diet, mental depression, fatigue, collectively, 
invariably produce terrible effects; whilst in a large number of acute 
affections of the severest kind, recovery occurs without a resort to any 
active remedy, merely under general hygienic measures. — C] 



FOOD. 

641. The purpose of food being the supply of materials, which when 
prepared by the process of digestion, shall repair the waste of the body 
and maintain its temperature, it is obvious that this purpose will be best 
fulfilled when the materials supplied are of such quality and quantity, 
and so administered as to suit respectively the powers of digestion, and 
the wants of the system for nourishment and warmth; in other words, 
food should be digestible, nutritious, and calefacient, and the articles 
which duly comprise all these qualities will be the most wholesome food. 

642. The importance of a due combination of the chief alimentary 
principles, albumen, oil, sugar or starch, with water as their diluent, has 
been before pointed out (§ 58) ; and the expediency of preferring such 
materials as comprise these in the best quality or condition may also be 
inferred from preceding observations (§ 60). It may not be superfluous 
to exemplify these points further by a few comments on common articles 
of diet. 

Wheaten bread comprehends the albuminous (gluten) and the amyla- 
ceous principle, and only needs the addition of butter to complete the 
requisite combination for moderate nutrition. The goodness of bread 
depends not only on the character of the grain from which the flour is 
obtained, but also on the mode and degree of its fermentation and baking. 
If fermented with leaven instead of yeast, or if over-fermented, acetic 
acid is generated and the bread is sour, and this is the common fault of 
bread in large towns where the supply of yeast is insufficient, and it pre- 
vails universally on the continent. This evil is avoided in the unfer- 
mented bread, which is rendered porous by an effervescence of carbonic 
acid gas, caused by an admixture of carbonate of soda with the flour, 
and hydrochloric acid with the water, of which the bread is made; when 
well prepared such bread is very sweet and free from acidity, but unless 
carefully prepared is liable to be heavy, and like imperfectly fermented 
bread it is then unfit for mastication. Bread insufficiently baked is glu- 
tinous and indigestible, and much of the same objection applies to quite 
new bread which has not dispersed its moisture. These defects may in 
great measure be remedied by toasting the bread in thin slices, which 
has also the advantage of dispersing much of the acid from sour bread. 
Very white bread is objectionable as being less nutritious (having less 
gluten) and more constipating than that made with less refined flour: 
but the coarse material commonly sold as brown bread errs to an oppo- 



392 



HYGIENICS. 



site extreme, in containing a bran so coarse as to be irritating to many 
stomachs. Good country bread fermented with yeast, and well baked, 
presents the kind most generally wholesome. 

Meat comprises the albuminous, oity, and gelatinous principles, be- 
sides creatine and other soluble extractive matters, which are probably 
nutritious. It requires combination with vegetables or bread to make it 
suitable to the palate and stomach. The object of keeping and cooking 
meat is to make it so tender as to be easily softened by the gastric juice, 
and all processes which interfere with or go beyond this result, render 
meat less wholesome. Thus salting or pickling, keeping until it be- 
comes tainted, or hardening it by over-cooking or fast boiling, which 
corrugates and toughens the fibre, are so many means of spoiling the 
meat for the purposes of digestion, and rendering much of its nutriment 
unavailable. The flesh of young adult animals presents the greatest 
amount of fibrinous nutriment ; that of younger animals contains more 
gelatine and fat; and that of older age is tough from the prevalence of 
fibrous textures, which being gelatinous are more serviceable for soups. 
The kinds of animal food vary much in their composition, even when 
the lean parts only are selected. Thus beef and pork contain a large 
proportion of fat ; mutton somewhat less ; veal still less; and in the flesh 
of fowl, game, and white fish, there is only a small amount. This affords 
an explanation of the fact that the latter articles are the best suited to 
persons of weak stomach. But the proportion of creatine and colored 
extractive doubtless also determines the quality of the food; thus the 
flesh of hare which contains much, is more heating than that of chicken 
and whiting or sole, which may be taken as the representatives of the 
mildest form of solid animal nourishment. Soups and broths, when 
deprived of excess of fat, are very useful articles of auxiliary nourishment 
in combination with solid food, but they are not substantial enough to 
supply a meal to a healthy person. Eggs and milk respectively, sepa- 
rately or combined, form light and nutritious articles of animal diet. 
They are rendered easier of digestion by being heated to about 180°, by 
which part of the albumen is slightly coagulated. Both eggs and milk 
contain a considerable amount of oil, which causes them, when taken too 
freely, to disagree with persons of bilious habit. So likewise, they are 
prone to speedy decay, and lose much of their wholesome nature, even 
in a. day or two. In like manner, fresh butter is an excellent adjunct 
to bread and vegetable articles; but speedily becomes rancid and loses 
its salubrious properties. Cheese is a low f©rm of protein compound, 
which requires energetic digestive and assimilating powers to raise it to 
the higher standard of the material of the plasma of the blood ; it is there- 
fore wholly unfit for delicate persons and those of w T eak digestion. 

Oleraceous and succulent vegetables and fruit are fit adjuncts to the 
more nutritious articles of food, which they serve to dilute ; and by the 
subacid and extractive matter which they contain, they promote the 
secretions, and thus tend to purify and cool the blood. In most instances 
they require to be thoroughly cooked to give them the state of softness 
fit for the digestive process. 

643. The choice of food and the arrangement of hours for different 
meals must vary much according to the habits and necessary occupations, 



FOOD. 



393 



as w T ell as the strength and tastes of individuals; but the following plan 
of diet, with some variations, will be found well suited to the majority of 
healthy adults. 

Breakfast at from eight to nine, a. m., of bread or dry toast w T ith a 
moderate quantity of butter. One or two new laid eggs, boiled three 
minutes and a half; or a little cold chicken or game, or even a mutton 
chop, may be added for those who use much bodily exertion. Beverage, 
one breakfast-cupful of cafe au lait ; that is, clear strong infusion of 
coffee w 7 ith scalded milk, in proportion of one-third of the former to tw T o- 
thirds of the milk. Cocoa deprived of fat, or thin chocolate with milk 
may be substituted. 

Luncheon at from one to two, p. m., may consist of a small basin of 
good shin of beef soup, with vermicelli, rice, or toasted bread in it. If 
meat have been taken at breakfast, a biscuit or piece of bread and butter, 
or small sandwich may suffice for luncheon ; wine and malt liquors are 
generally better avoided at this time, unless dinner be taken at this hour. 

Dinner at from five to seven, p. m. (The later hour is not recommended, 
but is often unavoidable.) Wholesome fresh meat and vegetables, well 
but plainly cooked, served hot, carefully proportioned, properly masti- 
cated ; varied from day to day, w r ith simple additions of fish, and mode- 
rate quantities of farinaceous or fruit puddings. Highly seasoned dishes, 
pickles, salted and dried meats, rich and heavy pastry, and cheese, 
except as a mere relish, to be excluded from a table professing whole- 
someness. Beverages: sound white wine, (sherry or good Marsala, 
from one to three glasses,) w r hich is generally better mixed w 7 ith water; 
or sound Sauterne or Moselle unmixed. Those who use much exercise 
may substitute sound malt liquor, bitter ale being the lightest, and good 
porter or stout the more sustaining. Half a pint is generally as much 
as is good for the health. Many thrive well, especially in the country, 
without any fermented liquor. If w r ateris taken it should be in modera- 
tion, otherwise it may interrupt digestion. Some find w T arm water or 
milk and w r ater a pleasant beverage. The habit of taking wine after 
dinner is one of luxury, not of health, and all that can be said of it in 
hygienic instructions, is — the less the better. The practice of taking a 
little fruit at the same time is not equally hurtful, provided by its quality 
or quantity it do not excite indigestion. 

Tea. The English custom of taking tea, or a simple w-arm liquid meal 
three or four hours after dinner is a very salutary one, and probably dis- 
agrees only w T ith those who dine too late or overload the stomach at din- 
ner. The purpose of the warm liquid is to assist in the separation and 
absorption of the chyle from the chyme which takes place at this period. 
And it is obvious that it w T ould interfere w 7 ith this process to introduce 
solid food into the stomach ; therefore little or nothing should be eaten — 
certainly not quantities of buttered toast, rich cake, and the like. Two 
or three moderate cups of black tea wdth a little milk and sugar, forms 
as a w T ash to the stomach to carry away the taste and smell of dinner, 
and remove all acrid materials, left by digestion, which might disturb 
that rest for which the hour now approaches. 

644. The practice of dining early, at from one to three p. m., which 
is pursued by the majority of persons in the lower and middle ranks of 



394 



HYGIENICS. 



society, would deserve more general adoption on the score of health, 
were it not generally impossible then to devote the time to it, and to rest 
after it, that the principal meal requires. A hurried early dinner, if 
enough to satisfy the appetite, is pretty sure to cause indigestion, and 
disqualifies for exertion afterwards. If, on the other hand, it be pur- 
posely made light; it may not suffice for the wants of the system, and an 
evening meal or supper will be necessary. The chief objection to sup- 
pers is that they are indulged in either so freely or at so late an hour, 
that their primary digestion is not accomplished by bed-time. Hence 
flatus and other symptoms of indigestion occur on lying down, and may 
prevent or disturb sleep, and the individual rises on the following morn- 
ing with a pasty mouth and unrefreshed. To avoid these consequences, 
the supper should be taken at least two hours before going to bed ; and 
should consist of such light nourishment as is easy of digestion, not too 
bulky, and not disposed to generate flatus. Those who use much exer- 
cise may take with advantage a little light meat, chicken, game, white fish, 
or lightly dressed eggs, with a small quantity of wine and water, or 
sound beer (if this do not disagree). Those who require less sustaining 
food, as sedentary, plethoric, or inflammatory individuals, will find a 
more suitable supper in a light farinaceous pudding, bread and milk, or 
oatmeal porridge ; the last being especially useful in persons of costive 
habit. A few currants, raisins, or a little apple with farinaceous pud- 
dings counteract their constipating tendency. 

A habit of regularity in the hours of meals is of great importance in 
the preservation of health. The stomach acquires the habit of expecting 
and the power of digesting food at regular intervals, and various disturb- 
ances in its function and in the system result from irregularity. For this 
reason it is much better for those who cannot always dine early, to keep 
regularly to the late hour. The evil effects of long fasting are partly 
dependent on the infraction of this rule; but ^ome result from inanition, 
w T hich has been noticed under the head of causes of disease (§ 63). 
Few delicate persons can bear much exertion of body or mind before 
breakfast : the practice of an early morning w T alk is only suited to the 
robust, w T ho feed largely and late on the preceding day. When it is borne 
in mind that food is intended not only to supply the slower process of 
nutrition and reparation of the body, but also to afford materials for the 
immediate protection of the blood against the chemical action of the 
oxygen absorbed in respiration, and of the stomach against the chemical 
action of the gastric juice, — the injurious tendency of long fasts will 
become apparent, and the more so in proportion as the small capacity of 
the digestive powers limits the quantity of aliment taken at a time. 



CLOTHING. 

645. The acknowledged purpose of clothing, as means of preserving 
the health, is to maintain as much as possible such an equal warmth of 
the surface and extremities of the body, as may conduce to the comfort 
of the feelings, and promote a free circulation, with sufficient perspiration 
and innervation in all the external parts of the body. But the healthful 



CLOTHING. 



395 



operation of clothing is not confined to its property of retaining warmth. 
It is useful also in protecting the body against the injurious influence of 
external heat, dryness, moisture, and electricity; and varied modifications 
of the clothing will best answer these several ends under different circum- 
stances. 

The lower animals exhibit many interesting facts showing instinctive 
or natural provisions for changes in their clothing to suit variations in 
season and weather, from some of which we may derive useful instruction. 
The change of coat in horses takes place in spring and autumn, and 
depends much on the character of the season ; the thick winter coat being 
slow to come off in a cold spring, but soon changing in continued warm 
weather: so likewise cold weather in the autumn accelerates the thick- 
ening of this coat, which in horses left to nature we find abundantly 
provided before the severity of the weather is established. Sheep change 
their wool only once in the year: but its rapid increase before the winter 
sets in, and its tardiness in loosening and falling off until June when all 
the cold winds of the spring have passed by, afford useful suggestions as 
to the propriety of anticipating the cold by the protection of dress, and 
of patiently awaiting its subsidence before we remove that protection. 
Birds moult their feathers early in the autumn; at which period the new 
plumage thickens in down and feathery expansion as the winter sets in. 
In the spring many of the downy feathers drop off, and are by many 
tribes appropriated to the lining of their nests; and through the summer 
the feathers continue to get thinner until the moulting season, when all 
give place to the new plumage. 

But attentive observation of the phenomena and habits of animals 
displays to us further means by which the same coat or plumage varies 
in its protective power with changes of the weather as well as of season. 
Thus cold causes a partial erection (§ 120) of hairs and feathers, which 
h?s the effect of increasing the thickness of the covering which they 
form, and this retaining in its interstices a layer of warm air, increases 
its non-conducting and protective power. On the other hand warmth 
occasions hairs and plumage to lie close and smooth, so that they form 
a covering which is thinner, and more readily permits the escape of 
heat. Horses which are exposed in the winter often roll in dirt and 
mud, which concreting in their winter coat gives to it a thickness and 
power to resist heat, which it would be unwise to remove by the process 
of grooming. Hence curried horses require artificial clothing. The 
feathered tribes are generally protected from wet by their imbricated 
plumage, wdiich is rendered more effective by the drooping direction 
which they give to their tails and feathers when exposed to rain. But 
they are supplied with another means of rendering their covering water- 
proof, in the oil with which their feathers are imbued. In aquatic birds 
this is so abundantly afforded from the skin itself, that their plumage 
scarcely ever becomes w T et. In other birds there is less fat in the integu- 
ments; but the defect is supplied by the instinctive habit of pluming and 
oiling their feathers, with frequent inunctions, derived from the large oil 
gland over the tail. It is curious to observe how domestic poultry spend 
the greater part of a wet day in this occupation, which is no doubt 
luxurious as well as useful. Another habit which may be contrasted with 



396 



HYGIENICS. 



the preceding, is noticed in warm dry weather; that of throwing dust or 
ashes into the plumage; perhaps the object is to remove any superfluity 
of oil, or it maybe only to relieve themselves from the irritation of vermin 
with which they are always infested. Some land birds, more rationally, 
delight in washing under the same circumstances. 

The preceding facts are not devoid of instruction in regard to the dress 
of human beings, who should learn to cover their nakedness under the 
guidance of experience and reason, which may be better or worse than 
instinct, according to whether they are well or ill exercised. It argues 
little for the boasted superiority of man's reason, if it do not guide him 
to means more effectual in resisting the hurtful action of external tem- 
perature than those instinctively possessed by the lower animals ; and 
yet there can be little doubt that none of these suffer from cold, wet, 
and atmospheric changes, to the degree in which human beings do. In 
truth reason and common sense are too frequently set aside by foolish 
habits originating in vanity, fashion, caprice, prejudice, indolence, ig- 
norance, or some such evil influence, and disease and infirmity are the 
penalties incurred by folly. 

It will be the most convenient and concise mode of practically im- 
proving the subject of clothing, by considering the modes in which the 
physical influences which injuriously affect the body may be best inter- 
cepted by articles of dress. 

646. We guard against external cold, by covering the body with 
such materials as by their low conducting power and thickness, prevent 
the undue escape of animal heat. The most effectual for this purpose 
are furs and woolen fabrics; next rank thick spongy silk and cotton 
stuffs; and the lowest in power are linen cloth, and silk and cotton 
webs, so thin as to lose their protective property. The porosity of furs 
and woolen garments is valuable in permitting the escape of insensible 
perspiration, and on account of its lightness; but it impairs their protec- 
tive quality against strong currents of cold air, especially if this be either 
very dry or very damp. Cold air in strong motion penetrates woolen 
stuffs of considerable thickness, and carries with it a dry or damp chill 
according to its hygrometric condition. In this power of penetration it 
is probably aided by the law of diffusion of gases (which applies to dif- 
ferent amounts of watery vapor in air (§ 72). This consideration will 
account for the peculiarly chilling operation of a desiccating east wind 
and a cold fog; and the interference of both with the cutaneous perspi- 
ration as well as circulation, explains much of their injurious influence. 
The best protection against these agents, is to be found in leather or even 
more impervious textures, such ss India rubber cloth or oil-cloth; but 
these should not be w r orn too near the skin, lest they should prevent 
the proper escape of its perspiration, and cause an unhealthy dampness 
of the surface. Chamois leather may be used as a waistcoat over one 
made of flannel ; and the still less pervious textures maybe employed 
either in detached pieces, as in the piline and india rubber chest protect- 
ors, or loin-belts, or in way of an outer garment as in Mackintosh capes, 
cloaks, and overalls, and these should be provided with ventilating 
apertures under the arms and elsewhere, to permit the free escape of the 
cutaneous exhalations. In this way we somewhat imitate the covering 



CLOTHING. 



397 



of birds, which in their flight are much exposed to cold winds, damp or 
dry; their plumage being porous and downy underneath, but denser and 
impervious externally, whilst by the overlapping of their feathers a free 
escape is left for the exhalation from the skin. A similar advantage is 
obtained in an inferior degree by using several garments of different 
degrees of permeability, the warmest and most porous being worn next 
the skin, and others externally; this alternation of successive layers of 
different properties increases the non-conducting power of clothing, and 
reduces the penetrative influence of cold and damp. There are very 
few instances in which flannel or fleecy hosiery may not form the best 
under dress during at least eight months in the year in this country, and 
a thinner material of the same kind, or merino, (a mixture of wool and 
cotton,) during the remaining four. The exceptions are persons of very 
irritable or relaxed skin, for whom an elastic cotton or spun silk material 
may be more suited. Warm under-dresses should not be w r orn in bed, 
as they then are apt to relax the skin too much, and render it more 
susceptible to the impressions of cold during the exposure of the day. 
Calico is the best material for the night dress ; any required additional 
warmth being afforded by the bed-clothes. It is of great importance 
to maintain the warmth of the extremities; there are few who can safely 
dispense with warm worsted stockings in the winter months ; and those 
liable to coldness of the feet should also wear flannel or merino drawers 
and flannel linings to their shoes and boots. 

647. Some of the kinds of clothing best suited to protect the body 
from wet and damp, have already been mentioned in the water-proof ma- 
terials which also prevent the penetration of cold winds. For the exclu- 
sion of w r et they should be worn outside of all other clothes, for the sake 
not only of permitting a freer escape of perspiration, but also of prevent- 
ing the penetration of moisture into any part of the dress, for although 
the wet may not reach the body, its proximity may chill by evaporation. 
For the same reason the cardinal rule of keeping the feet dry is better 
accomplished by outer coloshes, gutta-percha soles, and varnish, or other 
means w T hich exclude the wet on the outer surface of the shoes, than by 
inside cork soles or oil-silk socks, which allow the leather to be soaked 
in wet, and only intercepts its contact w 7 ith the foot. 

648. The change from winter to summer clothing should be made gra- 
dually and with great caution; and it is better to be tardy than hasty in 
change. The fitting period will vary in different seasons, but it rarely 
occurs before the month of May, often not until June; for although there 
may be warm weather earlier, it is generally of brief duration, and is 
alternated w 7 ith bleak w T inds which render the spring months peculiarly 
trying, and often cause more illness than all the continued severity of 
the winter. Much of this is to be attributed to the too early change of 
dress (§ 645). The converse rule may be applied to the change at the 
end of the summer; which is most prudently made in anticipation of 
the permanent cold. Many of the autumnal diseases arise from the 
great variations of temperature between day and night, and from sud- 
den changes of wind, and these take more effect by finding the body re- 
laxed by previous heat (§§ 25, 81), and yet protected by only summer 
clothing. 



398 



HYGIENICS. 



649. In this country even in summer the clothing is required to main- 
tain sufficient warmth, more than to exclude heat; but it is now reduced 
to the thinnest and lightest materials, a slight woolen or cotton fabric 
being commonly retained next the skin to prevent the chilling dampness 
of the linen when wet with perspiration. Frequent changes of linen, 
where practicable, might supersede this precaution, and with free ablutions 
are wholesome and refreshing during intense heat. Protection against 
solar heat and hot air is best afforded by loose linen vestments of light 
color, large straw hats, bonnets, veils, &c, which it is unnecessary to 
particularize. 

650. It is very probable, that atmospheric electricity may exert an 
influence on the health, which may be, in some degree, counteracted by 
modifications of the dress. Thus silk vestments have a considerable 
protective influence by their property of non-conduction; and if worn 
next the skin, by friction they excite electricity, which is supposed by 
some practitioners to operate as a hygienic agent, in persons disposed to 
rheumatic and nervous diseases. Further observations, carefully con- 
ducted, are needed to determine these points. 

651. Under particular circumstances or conditions of the system, 
additional warm clothing is necessary; such as — in infancy, when the 
calorific power is low; in old age; in convalescence from acute diseases ; 
during fatigue and other states of weakness ; and in organic diseases of 
the heart, when the circulation is feeble ; in case of privation of food ; 
during the operation of purgative or diaphoretic medicines; and when 
circumstances prevent the use of a proper amount of exercise. Under 
the influence of these conditions, the feeling of chilliness, particularly 
on the surface and in the extremities, is an indication of the need of 
more clothing; and if this be used to prevent the sensations of cold it 
will often counteract those disturbances of the circulation and internal 
congestions to which the weakened body is liable (§§ 79, 292), and which 
lay the foundation of many diseases. 

No part of the frame requires the protection of clothing so little as the 
head and face. The final cause of this comparative freedom from the 
bondage of garments, is obvious in a part where free communication with 
the exterior is necessary for the senses, breath, speech, and nourishment. 
The physiological cause of the greater power of the head in resisting 
cold, may be probably found in the larger size and less varying calibre 
of its blood-vessels (§ 266), which, even in weakened states of the cir- 
culation, secure an amount of blood which may cause a sense of heat 
and fulness, when other parts are suffering from the opposite feeling 
(§§ 330, 331). But even for the head, during exposure to the air and 
during the night, it is expedient to use such light covering as may pre- 
vent checking the perspiration of the surface, and more particularly the 
ceruminous secretion in the ears, the proper continuance of which is 
essential for the preservation of hearing. I do not, therefore, approve 
of a favorite modem practice of altogether discarding nightcaps, and I 
have known it to induce catarrhal affections of the eyes and nose, earache, 
and deafness. Those who thus suffer, or from dryness of the scalp, 
may find much benefit from wearing at night an oil silk cap over a thin 
nightcap. 



AIR AND TEMPERATURE. 



399 



Various other cautions and directions with regard to clothing are suf- 
ficiently dictated by principles of common sense to supersede the need 
of our dwelling on them, — such as the frequent changing of garments, 
especially under ones, for cleanliness sake; the avoidance of all tight 
ligatures, lacings, or buttonings, which may cause improper pressure on 
any part of the body, and interfere with free motion, circulation, perspi- 
ration, &c. The invention of India-rubber web and other elastic mate- 
rials, has supplied a valuable means (not used so generally as it deserves) 
of avoiding these evils, and of yet maintaining a due apposition and 
attachment of various articles of dress. 



AIR AND TEMPERATURE. 

652. The subject of impure air as a cause of disease, has already 
occupied our attention (§§ 72, 73): we now have to notice the states 
of the air most conducive to health ; and inasmuch as temperature is 
chiefly conveyed through the air surrounding the body, it will be con- 
venient to include a few remarks on this topic under the same head. 

The invigorating influence of pure fresh air may be partly referred to 
its superior purity more perfectly adapting it to the purpose of respira- 
tion, but somewhat of its refreshing effect is due to its direct operation 
on the nerves and capillaries of the surface of the body, and through 
them on the functions generally. This is exemplified in the reviving 
effect of a current of fresh air, or of fanning, on persons in a state of 
faintness, and this effect is more remarkable, when the air is cool and 
the body has been previously weakened by heat and confinement ; but 
the continued action of a cold current would be hazardous under these 
circumstances. The less marked but more enduring benefits of fresh 
air, are experienced in rides, drives, or other exercises, passive or active, 
which are universally acknowledged to be essential means of maintain- 
ing the bodily health. To obtain the greatest amount of good from these 
airings, it is useful not only to resort to localities where the air is most 
pure and free from contamination, but also to vary its qualities in other 
respects. Thus the inhabitants of valleys derive benefit from the air 
of hills; those of inland places, from that of the sea; and residents on 
the sea-coast derive advantage from drives inland. For a similar reason, 
much improvement of health often results from continued traveling by 
land or sea, and although this comprises other hygienic elements besides 
change of air, experienced travelers rarely fail to distinguish this as one 
of sensible efficacy, exercising a marked effect on the several functions. 
Similar beneficial results sometimes ensue from moderate and favorable 
changes of weather, which bring an altered state of atmosphere even to 
our own homes. It is by no means certain on what physical properties 
depend the all-varying hygienic influences of air in changing weather 
and different localities; but it may be useful to notice somewhat of the 
operation on the body, of air in different states of dryness and moisture, 
temperature and purity. 

653. A very dry air exerts on the body the physical influence of rapid 
evaporation and a high degree of electric tension; the resulting opera- 



400 



HYGIENICS. 



tion on the functions is generally more or less stimulating. The tonicity 
of the textures is usually augmented, whilst the desiccating, and proba- 
bly also the electric action of the air on the cutaneous and mucous sur- 
faces, induces an excitement which is beneficial in those of relaxed and 
leucophlegmatic habit ; but in the irritable and sanguine, may lead to 
inflammation or fever. A very dry air, the effect of which is increased 
by its heat or motion, impairs the perspiring power of the skin, and ex- 
cites various kinds of cutaneous inflammation, often with fever and 
thirst. In moderate degrees, and at mild temperatures, dryness of the 
air is salutary, by facilitating the purification of the blood in the lungs 
(§ 72), by improving the tone of the moving fibre, by checking tenden- 
cies to excessive secretion, and by counteracting various septic processes 
both within and without the body, which are generally promoted by 
humidity. We formerly had occasion to notice that dryness of the air is 
one of the best safeguards against the activity of miasmatic poisons (§ 83). 
Another reason for commonly preferring a dry air as the most healthy, is 
because we can more efficiently counteract the injurious operation of 
dryness than that of moisture. A judicious use of bathing, warm or 
cold, exercise and friction, which by inducing gentle sensible perspira- 
tion remove the dryness of the skin; the prevention of too rapid an 
evaporation from the surface by means of inunction, emollient applica- 
tions, and difficultly pervious coverings such as oil-silk, leather, &c, on 
parts which suffer, will generally succeed in preventing the hurtful in- 
fluences of dryness in the air without interfering with its salutary effects. 

Dryness of the air is most permanently obtained in connection with a 
dry soil, from which the water of rain and dew speedily drains off, or 
evaporates, as on rocky surfaces ; or sinks deeply, as in sand, chalk and 
light gravel. The nature of the subsoil is therefore of the greatest im- 
portance in determining the character of the air of a locality; and the 
kinds above mentioned are the most favorable to permanent dryness of 
the air. A declivity or undulating surface and a freedom from dense 
foliage and very luxuriant vegetation, contribute also to the dryness of 
a neighborhood, and generally thereby to its salubrity. Dryness in the 
air is also remarkably connected with the prevalence of certain winds in 
this hemisphere, especially those from the east, the aridity of which is 
due not only to the much rarer occurrence of rain which they bring with 
them, but also to their smaller proportion of dissolved moisture. And 
because such winds prevail more in strength and frequency on the eastern 
than on the western portions of these countries, the former have for the 
most part a drier air than the latter. But in addition to dryness, easterly 
winds have other qualities which detract much from their salutary in- 
fluence on the animal frame, and often prove positively injurious. Thus 
the north-east and due east winds are. remarkable for their bleakness and 
penetrative coldness (§ 646); and except in persons whose circulation is 
naturally strong and kept in activity by exercise, their tendency is to 
check the passage of the blood in the surface and in mucous membranes, 
and impair the functions connected therewith. Further, the objection to 
exposed situations on account of the capricious and changeable character 
of the winds w T hich act on them, applies with peculiar force to those 
with an eastern aspect, on which the transition is more than usually 



AIR AND TEMPERATURE — MOIST AIR. 



401 



sudden and extreme, from the power and bleakness of the returning 
cold. 

The south-east wind is also dry, and in winter and spring differs 
from those more from the north in its milder temperature ; but as sum- 
mer advances it is remarkable for its sultry and oppressive quality, which 
in south Europe is exemplified in its acme in the operation of the sirocco. 
Much of the overpowering influence of this air may be explained by its 
desiccating operation, (manifest not only in animals by the thirst and 
feverish dryness of the skin and mouth, but also in plants and trees by 
the drooping of their leaves,) combined with the relaxing agency of heat 
on the vascular fibre, by which the powers of the circulation are enfee- 
bled, and the purifying processes of respiration and secretion are more 
or less impaired. But doubtless something of the peculiar effects of a 
south-east wind is due to electric tension ; and in this country their ex- 
treme manifestation generally precedes the occurrence of a thunder storm ; 
nor should be forgotten the fact formerly mentioned (§ 92 note), that dur- 
ing the prevalence of this wind especially the air becomes surcharged 
with animalcule tribes, and certain epidemic diseases, especially Asiatic 
cholera and sometimes influenza, make their greatest progress. 

654. A damp or moist air, irrespectively of its temperature, may be 
considered as lower than dry air in its vivifying power, inasmuch as it 
contains less free oxygen, and has a lower diffusive property to aid in its 
pervading the lungs in respiration. The greater facility which it affords 
to processes of decomposition and infection should also be scored against 
its salubrity, as well as other points in which it may be contrasted with 
moderately dry air. A warm moist air is universally relaxing (§§ 25, 
123), and unless in persons of dry skin and over-braced vessels, is 
oppressive and debilitating. Under its influence, perspiration accumu- 
lates on the surface, perpetuating its relaxation if warmth continues, and 
chilling it and impairing its circulation and excretion if cold ensues; and. 
the very evaporation from the moistened surface, which even in mild 
damp air may occur from draughts or currents, may under such circum- 
stances cause an injurious chill. More surely pernicious in this manner 
is cold damp air, w T hich is proverbially unhealthy, and its disordering 
action may be in great measure traced to the physical properties of ab- 
stracting heat and electricity, and of checking perspiration and assimila- 
tion, which it obviously possesses. Hence ensue the retention of lactic 
acid in the blood, the formation of oxalic instead of lithic acid, and the 
imperfect elaboration of the plasma; and these aberrations from the 
normal chemistry of the body, may manifest themselves in the shape of 
various diseases of the blood and circulation, of w r hich rheumatism, 
neuralgia, sundry cutaneous affections, cachectic ulcers, tubercles, scro- 
fula, &c, are familiar examples. 

The most efficient cause of dampness in the air is the permanent 
retention of moisture on or near the surface of the ground, as in low 
grounds in which clay prevails, and where water accumulates or is im- 
perfectly drained off, and where evaporation is retarded by the shade of 
many trees, or of high rocks or hills. But independently of soil, a house 
may be damp from its own materials, which from recent construction, or 
from their tendency to attract and precipitate humidity (as in case of 
26 



402 



HYGIENICS. 



those built of limestone or marble), are constantly impregnating the con- 
tained air with humidity. Wet weather and damp winds, such as the 
south-west, are less injurious causes of humidity, because less permanent ; 
but their influence is often manifest during their continuance, and always 
most so in localities that are damp from other causes. The air of the 
sea-side, even on the south-west coast, although generally abounding in 
humidity, is far less injurious than that of damp places inland ; appa- 
rently because much of the sedative and chilling operation of marine 
humidity is counteracted by the stimulating influence of the saline par- 
ticles which it contains. The different effect of a sea fog and a land 
mist is well known. 

The hygienic directions with regard to moist air are chiefly of a pro- 
tective or counteracting character. Artificial heat is the most available 
and efficacious desiccating agent which we can command; and if com- 
bined with adequate ventilation, it may do much to remove dampness of 
air within doors, whether arising from the soil or from the building. In 
warm weather, when fires are unpleasant, much unhealthy moisture may 
be removed from the air, by so adjusting doors and windows, or air holes, 
that ventilation may be secured without opening those facing the dampest 
vicinity. In limestone districts, much good results from keeping large 
pans of quicklime in several apartments, especially those of the basement 
and ground-floor. This expedient, for reasons before mentioned, is a 
serviceable precaution against malarious and infectious diseases; its 
utility has long been known in preventing meat from becoming soon 
tainted in a damp larder. 

To diminish the dampness of clay and marshy soils in the immediate 
vicinity of dwellings, much may often be done by an efficient system of 
covered drainage; by the removal of superfluous trees and shrubs; and, 
where practicable, by covering the surfaces which are most constantly 
wet, with light sand, gravel, brick and mortar rubbish, or some similar 
light and porous material, which may form an artificial superstratum and 
intercept the influence of the damp ground. The insalubrity of many 
low parts of the metropolis, especially in Pimlico and Westminster, has 
been wonderfully diminished by the latter expedients. A parallel pro- 
tection against the damp of limestone walls of houses is obtained by the 
process of battening or covering the wall with wood and canvas, or lath 
and plaster. The free use of concrete, or of slate or metallic plates in 
the foundations of houses, to prevent the rising in the walls of moisture 
by capillary attraction, should never be neglected, particularly in damp 
localities, where the lower parts of the building are likely to be inhabited. 

655. The subject of temperature of the air has been frequently intro- 
duced in the preceding remarks, and it will be superfluous to dwell long 
on it here. The average temperature most generally conducive to com- 
fort and health, is about thirty-five degrees (of Fahrenheit) below the 
heat of the interior of the body; that is, 63°; blood-heat being 98°. In 
sustaining an artificial temperature in the air, it is rarely expedient to 
exceed this; for the purity and invigorating properties suffer at higher 
temperatures, and if more warmth is needed than what results from air 
at this point, it should be supplied by clothing or other, means. The 
advantage of keeping the atmosphere of apartments considerably cooler 



TEMPERATURE AND AIR. 



403 



than the body itself, consists, not only in the greater amount of oxygen 
contained in a given bulk, but also in the greater force with which the 
foul air of respiration is carried away from the breathing passages, and 
a pure air supplied, in consequence of the difference of temperature 
maintaining a current. The converse of this is a chief reason why 
over-heated rooms are peculiarly oppressive, unless the air be changed 
by efficient ventilation, and why warming rooms by stoves, or heated air, 
causes a feeling of closeness which does not result from open fire-places, 
which communicate heat chiefly by radiation, and leave the air compa- 
ratively cool. The animal body being naturally much warmer than the 
surrounding air, operates as a ventilator for itself, by the same consum- 
mate adaptation of pneumatic laws as that which supplies a flame or fire 
with a continued current of fresh air; and as we see a fire burn brighter 
and clearer in frosty weather, so an animal breathes a purer, denser air, 
which, if not injurious by its cold, is refreshing and invigorating to the 
body. Not only healthy and robust persons, but also some who are 
asthmatic, or otherwise weak in respiratory power, acquire increased 
strength and energy in clear cold weather ; and even those who, from 
weakness of circulation, cannot resist continued cold, and usually require 
a mild atmosphere, are generally refreshed and benefited by breathing 
cold air for short periods, when exercise and warm clothing protect them 
against its sedative and chilling effects. 

656. The use of artificial heat is greatest in young infants and very 
aged persons ; in whom the intrinsic calorific power is too low to bear 
safely even the temporary exposure to wintry air just mentioned as useful 
to some weakly subjects. So, too, those who suffer in the lungs and air 
passages from even brief impressions of cold, which is the case with the 
greater number of pulmonary invalids, should not venture into the open 
air during cold weather, without the protection of a respirator, which 
acts as a kind of clothing to the air passages ; and although it detracts 
from the refreshing coolness of the open air, it does not materially im- 
pair its purity. I have known this instrument prove useful also in the 
case of ansemic subjects, and others of low calorific power, not merely 
by protecting the air passages, but also by retaining the heat which is 
generally expended in the expired air.* 

657. The necessity of maintaining the purity of the air by its con- 
tinued change, has repeatedly been noticed in the present and preceding 
chapters (§ 72). In cold weather, this change is greatly promoted by 
the difference of temperature in the air heated by respiration or by the 
fire of a room, and that of the surrounding atmosphere, and the increased 

* Various expedients for retaining the warmth of the breast for the purposes of animal 
temperature, were long since recommended by Dr. Arnott and others. An incident in point, 
which occurred to myself many years since, may afford a useful hint to others in a similar 
predicament. I had to go a long journey on a cold winter's night; and there being no room 
inside the mail, I was obliged to ride on the outside, although insufficiently clothed for the 
exposure. Reflecting on the great loss of heat manifest in the steaming breath of myself 
and fellow-passengers, I endeavored to retain a portion of it by entirely covering the head 
and face with a silk pocket-handkerchief, the lower ends of which were closely tucked in- 
side the buttoned coat. The result was a retention of warmth, not in the face and chest 
only, but even in the extremities, more comfortable and diffused than an additional great 
coat could have produced. 



404 



HYGIENICS. 



ventilation thus insured has been mentioned as a cause of the more in- 
vigorating properties of the air in winter. In hot weather, on the other 
hand, and in apartments heated through the air more than by radiation, 
it is necessary to provide means to assist the motion of the air. In 
summer, this may usually be effected by open windows and doors ; and 
the close smell which shut-up rooms acquire in summer, generally sug- 
gests this remedy. In India, and other hot climates, where even the 
outer air is so hot and still that it supplies no movement, machines are 
used for creating a current of air, and of further cooling it by evaporation 
from a moist surface. Even sprinkling floors and walls with water is 
useful, not only in cooling the air, but also in thereby promoting its mo- 
tion. 

In cold weather some degree of ventilation is commonly insured by 
the fires employed for the purpose of warmth; but it is often in an irre- 
gular or insufficient manner; as by draughts of air under doors, and 
through the chinks of floors, which cause a cold current on the feet and 
lower parts of the body, whilst the head and breathing passages, which 
are above the level of the fire-places, are above the current, in a stratum 
of warm and less pure air. It is quite true that by the law of diffusion 
of gases, as well as by the force of the currents, and other means of agi- 
tating the air, a change is effected in the whole air of a room; but it is 
so, less completely and rapidly than is desirable for so important a pur- 
pose as the constant supply of pure air for respiration. To obviate these 
defects, various ventilating contrivances have been recommended, and 
none for simplicity and efficacy excel those recommended by Dr. Arnott, 
which not only form apertures calculated to promote a continued change 
of air in the room, but by means of a simple self-adjusting valve, they 
may be made to prevent too strong a current or one in a wrong direction. 
For perfect ventilation, two apertures (or sets of them) are requisite; one 
for the supply of fresh air, another for the exit of that which is foul. 
These should be placed at opposite sides of the room, and it is generally 
advised that the outlet should be placed near the ceiling, which is cer- 
tainly the best position ; and it may be made into the chimney where a 
fire is used (an efficient valve preventing the influx of smoke), or through 
the ceiling or roof, or in a top window pane, where there is no chimney. 
For the purpose of affording the freest influx of air, an aperture near or 
in the floor would be the most suitable position • but it is objectionable 
on account of the chill which it communicates to the feet and lower parts 
of the body. Commonly, therefore, the inlet for fresh air may be made 
in the upper pane of a window or panel of a door, most remote from the 
outletting aperture ; and to prevent draughts, and to promote the diffu- 
sion of the air through the room, the opening should be covered with 
wire-gauze, or finely perforated zinc plate, in addition to which, if neces- 
sary, an oblique screen of wood o^ curtain may be placed before it to 
direct the current to the walls and ceiling. By these means the fresh 
air, which is heavier, because cooler than the air of the room, gradually 
falls, and is dispersed, displacing the warmer foul air; and reaches the 
middle of the room cool and refreshing for the heads and breaths of the 
inmates, yet causing no draughts on the lower extremities. In very 
cold weather, it is certainly advantageous to have the supply of external 



TEMPERATURE AND AIR VENTILATION. 



405 



air moderately warmed before it enters the room ; and the best method 
of effecting this, is by means of a well-regulated warm air stove, or an 
Arnott stove, with a current of fresh air directed on it, placed in the hall 
or at the bottom of the staircase. This inlet of a gently warmed air, is 
useful, not only by taking the excessive chill from the outer air, but also 
by affording such an influx into the house as supersedes those irregular 
draughts, which, for want of other supply, force their way through every 
chink, hole, and cranny in the floors or walls, and which besides a chill, 
often bring with them dust and bad effluvia acquired in their passage 
from without (§§ 72, 73). The extreme dryness of the air thus warmed 
may be removed by shallow earthen pans containing water, placed on 
the stove. 

658. The ventilating force operating in all the cases hitherto noticed, 
is that depending on atmospheric pressure, displacing air rendered lighter 
by heat, animal or artificial; and this force properly applied and directed, 
will suffice for the ventilation of ordinary dwellings. But for large pub- 
lic buildings in which great numbers are congregated, or where other 
causes of contamination or impurity operate, as in manufactories, 
hospitals, mines, holds of large ships, &c, this force may be ineffectual; 
and even when aided by extra fires and lengths of chimney, it is not 
sufficiently under command or regulation to be properly adequate for the 
purpose. The other forces which have been applied to effect ventilation 
on a large scale, are mechanical powers, and the operation of a jet of 
high-pressure steam. The latter is very efficient in creating a strong 
current of air which is chiefly applicable to the drawing off of foul air. 
It is proposed to be applied by Mr. Barry, as a chief force in the ventila- 
tion of the new Houses of Parliament ; but time will show how far it 
will prove adequate. The noise caused by it would be an objection in 
some cases. Mechanical ventilation has long been practised through 
the revolving fan wheel ; but Dr. Arnott has shown that its propelling 
power is very limited ; for where resisted by any opposing current 
equal to the pressure of a column of seven inches of water, it no longer 
creates a current, but revolves with increased rapidity, carrying the air 
with it instead of through it. This scientific physician has devised a 
mechanical ventilating apparatus, which in amount and steadiness of 
power, and the perfect facility with which the air supplied can be regu- 
lated, excels every contrivance hitherto accomplished or proposed. Such 
a machine, which is a kind of pump, moved by steam, and which pro- 
pels air in a precisely measured quantity and regulated temperature, 
has been constructed under Dr. Arnott's directions at the Hospital for 
Consumption at Brompton ; and so far as can be judged from a trial of 
four or five months, appears to be perfectly successful in its operation. 
This machine introduces into the building about two thousand cubic feet 
of air per minute, which passing over six hundred square feet of surface 
heated by steam, supplies an abundant amount of fresh air, moderately 
warmed. The foul air escapes through valvular apertures into the chim- 
neys of each room. 

659. Besides the supply of fresh air to the interior of buildings, means 
to preserve from contaminating effluvia are frequently required, espe- 
cially in large towns. Systematic and scrupulous cleanliness, and an 



406 



HYGIENICS. 



adequate and air-tight drainage are most effectual for this purpose. 
Some recommendations on these subjects have been already given under 
the head of exciting causes of disease (§§ 70, 73). For the purpose of 
cleansing, an abundant supply of water is essential to the wholesome- 
ness of a habitation; the evils of impure air are commonly experienced 
where this purifying element is scanty. Additional means of purifica- 
tion are afforded by certain chemical agents which absorb or decompose 
noxious effluvia. Lime is a cheap and useful material for this purpose, 
and may often be advantageously used both by lime washing walls and 
ceilings, and by pans of quicklime kept in the basement story of houses 
near any source of foul air. Other disinfecting agents are still more 
powerful, and at the head of them undoubtedly stands chlorine, which is 
invaluable in destroying noxious effluvia, the source of which cannot be 
stopped. Chloride of lime, and dissolved chlorinated soda, are convenient 
materials to afford a moderate supply of the gas, which, if required, may 
be extricated in greater quantity by the addition of an acid. But a cheaper 
and more abundant source is supplied by black oxide of manganese, com- 
mon salt and sulphuric acid; the acid being added from time to time in 
small quantities throughout the day.* Under circumstances in which the 
operation of chlorine is too irritating, nitric or acetic acid vapor may be 
substituted, but they are less effectual and must be used in greater abund- 
ance. In houses in which unmanageable drains or immovable cesspools 
taint the air, some of these disinfecting agents should be kept in perpetual 
operation.! 



BODILY EXERCISE. 

660. The want of exercise has been noticed as predisposing to, and 
exciting disease (§§ 24, 65); and the opposite extreme, excessive exer- 
tion, was mentioned as equally detrimental in its effect on functions and 
structures (§ 64). The place which exercise occupies as a hygienic agent 
is therefore between these extremes ; and its utility and importance will 
be proportioned to the regularity and discretion with which it is prac- 
tised. 

Moderate and sustained exercise in healthy air, as in walking, riding 
on horseback, and in various occupations and pastimes, excites into ac- 
tivity most of the functions of the body, especially the circulation and 
respiration, or those intimately connected with these, the secretions and 
animal heat : and provided the fatigue or exhaustion resulting from this 
excitement be adequately removed by sufficient rest and sustenance, the 
functions gradually gain vigor by their activity, and the structures ex- 
ercising them acquire a fuller and healthier development. The muscles 
especially, including the heart, manifest an increas # e of strength and 

* A cheap and convenient apparatus for fumigating with these materials has been con- 
trived by Mr. Smith, of White-street, Borough, and to be obtained of Hoare and Co., 123 
Newgate-street. 

f The subject of public sewerage and others connected with these topics, is too extensive 
to be entered on here ; and the reader will find much valuable information in the Report 
lately published by the Sanitary Commissioners, from whose continued labors much good 
may be expected. 



BODILY EXERCISE. 



407 



firmness ; the blood-vessels are improved in tone, by which they distri- 
bute and equalize the flow of blood through them, and prevent partial 
congestions and obstructions; and the blood, actively carried through 
the organs and textures, undergoes the complete series of changes from 
nutrition, purification, and arterialization, by which its integrity is main- 
tained, and it is adapted in its turn to sustain the several functions of 
the body. The appetite, the digestive powers, the intestinal action, the 
warmth of the surface and extremities, the spirits and temper, are gene- 
rally all improved by the habit of regular exercise ; and what can we say 
more to recommend any hygienic agent? But as much of its beneficial 
effect depends on the judicious manner in which exercise is adapted, 
in kind, time, and degree, to the strength, habits, occupation, age, sex, 
and other circumstances of the individual, it may not be superfluous to 
indicate a few cautions and directions on the most important of these 
points. 

661. In childhood, youth, and early maturity, when the joints are 
supple, the textures in full elasticity, and the whole frame adapted to 
the quickest and most varied movements, diversity and activity in mus- 
cular action are suitable and salutary; and there is pleasure as well as 
benefit in exceeding common modes of exercise by varied feats of agility 
and strength, which "call into play all the muscles of the body, as in 
running, leaping, climbing, wrestling, rowing, and various athletic games, 
such as crickets, fives, tennis, quoits, &c. But at this youthful age 
there is less power of endurance of continued fatigue than in maturer 
life, and the body more absolutely requires repose after exertion. The 
health of young persons, especially of the female sex, is often much 
injured by too long w T alks, especially if frequently repeated, whilst they 
may comparatively suffer little from greater exertion for a shorter period, 
as in dancing, or riding on horseback. In adult age, on the other hand, 
prolonged exertion is better borne than exertions requiring great agility 
of movement; and unless a youthful mobility be preserved by continued 
practice, more sober and steady motions are more fitting to the sedate 
age. Exercise on foot and on horseback is the ordinary mode, except 
among the working classes, whose occupations engage them in various 
kinds and degrees of muscular exertion: and in all these species of ex- 
ercise and work, experience teaches long before the period of middle 
age, that more is safely and comfortably to be done by steady and sus- 
tained exertions, than by sudden or rapid efforts. But it does not there- 
fore follow, that the exercise taken for the sake of health in middle age 
should be monotonous or slow. Persons much engaged in employments 
either sedentary or confining them within doors with little exertion, 
would feel little benefit or refreshment from the hour or two which they 
can spare for out-of-door exercise if it were passed in mere sauntering 
or strolling on an unvaried road. A brisk walk, diversified as much as 
may be in direction, including, if possible, ascents and descents, and 
away from the vicinity of the smoke and effluvia in which the rest of 
the day is spent, and alternated with an inspiriting ride on a free-paced 
horse, or with the healthy exercise of active gardening, or the like pur- 
suit, will most profitably fill up the time which the middle-aged man of 
business can devote to exercise, and he will then soon find it a very safe 



408 



HYGIENICS. 



and remunerating investment. On the other hand, he who, forgetting 
what becomes his age, relishes no exercise but those associated with the 
excitements of the ball-room, the cricket-ground, the rowing match, or 
the hunting field, speculates with a capital of mobility and elasticity 
which he may not possess, and although he may sometimes boast of a 
successful result in recovering activity and health lost through previous 
habits, yet he encounters a perpetual risk of breaking down under the 
unusual strain to which he subjects his frame, and he gains none of that 
gradually renovating and invigorating influence which is produced by 
more moderate exercise regularly practised, although varied from day to 
day. In old age the sphere of exertion is still further limited by func- 
tional and structural changes before noticed (§§ 48, 546), and exercise, 
although still salutary, must be still further restricted in degree and va- 
riety. Quiet walking or riding on horseback may be practised by many, 
even far advanced in years ; and carriage exercise (such as it is, which 
is scarcely any) remains for the more infirm. The selection of these, 
and the extent to which they are beneficial, will depend much on the 
previous habits as well as on the present condition of the individual. If 
a man has lived a sedentary life, and has become stiff and prematurely 
old in consequence, this is not the time to commence habits of activity, 
which would endanger the integrity of his vegetating or mineralized 
structures (§ 543-6). A similar caution is applicable to those who have 
lived too fast, and by various excesses and undue excitement and strains, 
have exhausted their vital powers and accelerated the degenerative 
changes in their textures: such persons manifest by their feeble and 
tottering gait and breathlessness on exertion, an inaptitude for exercise, 
which should caution them against its being attempted. Carriage airings 
and gentle frictions of the surface and extremities are here the best sub- 
stitutes. It is different with those, who, by a temperate and judicious 
mode of living, with habits of activity proportioned to the strength and 
age, have economized their vigor, and given fair play to their constitu- 
tional powers: these may be said to enjoy a green old age, in which a 
capacity for moderate exercise continues to be not less a source of re- 
creation and comfort than a means of sustaining health; but even these 
fine and in all respects venerable specimens of ameliorated humanity 
sometimes need professional warnings against presuming too much on 
their well-husbanded strength. They are often carried off by acute 
attacks, which have been brought on by their stepping out of their sphere 
of safety, which, although wider than usual at their age, has nevertheless 
limits, which the steady hand of time is daily narrowing, but in so gra- 
dual and imperceptible a manner, as to escape the attention of their own 
mental powers, now also on the wane. Hence one act of imprudence 
may be followed by fatal results; and that may be deemed to be impru- 
dent which in any material degree exceeds the bounds of the accus- 
tomed habits. 

662. The times at which exercise is most salutary, in relation to meals, 
occupation and repose, are commonly those in which the bodily powers 
are not too low from fasting, fatigue, or wakefulness, nor oppressed by 
the process of digestion. Exercise before breakfast is suitable only to 
the robust, and those who have fed late and largely on the preceding 



BODILY EXERCISE. 



409 



day: delicate persons commonly become faint from exercise at this time; 
and others that do not immediately suffer, lose a degree of the appetency 
and digestive power which render the meal agreeable as well as useful, 
and thus consequently are more languid during the early part of the day. 
Shortly after breakfast is commonly an eligible time for exercise : this 
meal is sufficient to remove the squeamishness or faintness apt to arise 
from an empty stomach, yet it is not, or should not be, so heavy as to 
oppress the bodily powers, or prevent their capacity for moderate mus- 
cular exertion. Those who can command the time, will find it advan- 
tageous to intersperse their sedentary occupations with short periods of 
exercise, if possible in the open air ; if this be only for ten or fifteen 
minutes, once or twice in the course of the forenoon and afternoon, it 
will contribute to counteract the bad effects of confinement, and by giving 
a fresh impulse to the circulation and respiration, it will remove conges- 
tions, cool the head, warm the feet, and thus tend to refresh both body 
and mind. For similar reasons it is w T ell that more extended exercise 
should be taken twice rather than once daily, the second period being 
after the early tea, or before late dinner, as arranged under the head of 
Food (§ 643-4). Those whose occupations are fatiguing either to body 
or mind, and who are obliged to dine late, may not have strength suffi- 
cient to bear the second period of exercise before dinner ; but they may be 
enabled by an hour or two of rest after this meal to take an evening walk, 
which will be found w r ell-timed and refreshing, especially in the summer. 
Under all circumstances it is of importance to avoid much fatigue both 
before and soon after dinner. This being generally the principal repast, 
needs more than other meals, the undisturbed energies of the system 
for its digestion ; and if either the body is exhausted by exertion before- 
hand, or its energies are diverted from the digestive organs by exercise 
taken soon after the meal, the digestion will be disturbed, and various 
evil consequences may ensue. It is the chief objection to very late 
dinners, that after the toils of the w T hole day, the body is too much ex- 
hausted for the work of digestion, and stimulants are always needed to 
aid in the process, which they do but irregularly and imperfectly. 

663. The weaker or more delicate is the individual, the more neces- 
sary are the above-mentioned cautions against excessive or ill-timed 
exercise. The time to be devoted to bodily recreation will vary much 
with natural strength and habits, and the kind of exercise used. Females 
and delicate persons will rarely benefit by more than from half an hour to 
three quarters of an hour's walk, or nearly double those periods of gentle 
horse exercise: but robust males may find advantage in a considerably 
greater amount. 

664. Exercise varies in effect according to its kind. Walking, al- 
though giving some action to most of the muscles of the body, chiefly 
exercises those of the lower extremities ; and by increasing the circula- 
tion and perspiration, especially in that direction, it tends to derive from 
the head and chest, and to relieve congestions of these cavities. Riding 
on horseback gives more exertion to the loins, and by the regular move- 
ments which it communicates to the viscera of the abdomen, pelvis and 
thorax, it promotes their circulation and functions ; it is not equally 
effectual in equalizing the circulation in the head and extremities, and 



410 



HYGIENICS. 



in cold weather, especially, often causes headache, which may generally 
be prevented by taking measures to keep the feet warm. 

Some kinds of exercise which include alternate stooping and raising 
the body, such as digging and other occupations in the garden, are ser- 
viceable in promoting the action of the bowels and kidneys ; and the same 
remark will apply to various games of bowls. Rowing has the advan- 
tage of very generally and uniformly exercising the muscles of the 
whole body; but unless it be practised with moderation, the simulta- 
neous pressure which it exerts on every part may prove injurious, by 
overstraining the organs of circulation and respiration (§ 64); and many 
proofs have come within my observation of the evil consequences ot 
boat racing. ' 

MENTAL OCCUPATION. 

665. Under this head may be comprised a short notice of the mental 
influences which most conduce to the maintenance of health. As with 
the corporeal functions, so with the mind, a moderate and equable ac- 
tivity, with some variety of excitement and relaxation, contributes to 
its well-being; and inasmuch as the body is greatly under the influence 
of the mind (§ 66), the health of both is, therefore, equally promoted. — 
The kind and amount of mental exercise must vary considerably, ac- 
cording to different circumstances of age, sex, temperament, capacity 
and habits of the subjects. The topic is far too wide to be compre- 
hended in the very cursory glance which we can give to it, and it must 
suffice to notice some variations of mental discipline adapted to these 
different circumstances. 

666. In infancy, the sentient and perceptive functions are active, the 
emotional feelings lively, whilst the higher, moral, and the intellectual 
faculties are very imperfect. Hence the sensitive excitability of this 
age, which becomes a frequent cause of disorder; and to moderate this 
by various soothing expedients, as by gentle and lulling impressions on 
the senses, with timely resorts to varied amusing toys, and other objects 
to divert attention, and gently exercise the organs of sense and percep- 
tion, is the chief aim at this early period. But as infancy passes into 
childhood, there is sufficient development of moral feeling and under- 
standing to supply further means of control and direction ; and although 
at this age it is equally necessary to avoid causes of fretfulness and pas- 
sion, the principle of self-control and patience may now be properly in- 
culcated by moral and religious instruction, enforced by a consistent 
example of kindness and justice in the conduct of those who manage the 
children. The mental, as well as the bodily powers, at this early age, 
have no endurance, they are soon fatigued ; and nothing can be more 
hurtful than to excite them too much, or too long, by games or scenes 
of amusement; exhaustion, fretfulness and bodily suffering, are the 
common consequences of such excess, and disease not unfrequently 
follows. A similar objection may be urged against too early or too pro- 
longed attempts to educate the mind; such attempts anticipate the period 
at which the power of concentration, or sustained attention, is acquired, 



MENTAL OCCUPATION AND DISCIPLINE. 



411 



which it can be safely only by time and practice. Children precocious 
in intellect gain this power early, but this is a reason against its exercise, 
which would the more readily tend to strain the active faculties to a 
morbid degree. 

667. As the mental capacity becomes enlarged by equal and judicious 
exercise in ripening youth, it is adapted to longer and severer tasks, and 
in addition to the advantages of thus improving the intellect by extended 
occupation at this age, the moral emotions and animal passions, which 
now acquire strength, are hereby moderated and kept in subjection. — 
A leading rule to be observed in all attempts to develop and regulate 
the mind, is, to exercise its powers as equally as possible ; the natural 
tendency is, that those powers which are constitutionally strongest should 
overrule and weaken others, and this applies to the impulses of moral 
feeling as much as to intellectual capacity. A main purpose of educa- 
tion is to prevent the inequalities, by exercising the w T eaker powers, and 
judiciously restraining those which unduly predominate. Herein educa- 
tion includes not the mere communication of knowledge, but the disci- 
pline of the heart and mind ; the subjugation of evil and useless incli- 
nations and propensities, and the direction of the attention or activity of 
the intellect to objects that are profitable and improving. The influences 
by the aid of which this discipline may be exercised are manifold, and 
must, in some degree, vary with the age and with the character of the 
individual. In childhood, respect and love towards parents or others 
exercising authority; in youth, the same feelings confirmed and cultivated 
by the convictions of the understanding now giving increased sponta- 
neity of thought to the individual; and in all ages, the constraining and 
elevating influence of religion in supplying the highest motives and rules 
for the conduct of thinking and responsible beings ; these are the great 
leading instruments through which mental discipline is safely and effect- 
ually applied. But other and less dignified motives are often equally 
powerful, such as vanity, pride, ambition, rivalry and the like; and 
although they prove the failing of the human mind from a standard of 
perfection, and unless controlled may become exaggerated into vice, yet 
under restraint they may be usefully enlisted on the side of mental im- 
provement. 

668. When youth ripens into adult age, although technically speaking 
education is complete, the discipline and culture of the mind (which are 
the objects of education) are still to be carried on with all the activity 
proportioned to the full development of the faculties and passions. This 
being the period at which the authority of parents or seniors is more or 
less relaxed, and the individual is of age to take full responsibility on 
himself, it is of the utmost consequence that his mature pow T ers should 
be directed in a career which may promote his present and permanent 
welfare ; and much, in regard to his future health, depends on the pos- 
sessing such ascendency of mind over body, of moral over animal feel- 
ings, as may secure the establishment of wholesome habits of wisdom 
and temperance. The subjugation of gross appetites ; the subordination 
of all turbulent or violent moral and mental emotions ; the cultivation of 
the gentle and calming feelings fostered in domestic life or in refined 
social intercourse ; and the regular but moderate application of the in- 



412 



HYGIENICS. 



tellectual powers to some definite objector set of objects worthy of their 
pursuit ; — are items of mental discipline becoming the age of maturity, 
and if steadily practised cannot fail to conduce, not only to the health 
and endurance of both mind and body, but also to their lasting comfort 
and happiness. It is true that many difficulties beset the beginner in 
his endeavors to follow such rules ; many struggles against the inferior 
part of himself; much exercise of patience and forbearance in regard to 
others; a frequent practice of self-control in avoiding the temptations 
of excitement and intoxicating amusement ; and a constant vigilance 
over the mind, to restrain it equally from wandering into bye-paths away 
from its proper road, and from lapsing into desultory abstraction or in- 
dolence ; and these impeding forces within, are often prompted or seconded 
by not less formidable obstacles without, thrown up by the multitudinous 
and ever-rising temptations and trials of life — never absent, but often 
peculiarly besetting its anxious and unsteady commencement. Need 
we say, then, that the efforts should be proportioned to the difficulties ? 
and with the full and rational exercise of human means, but with hum- 
ble and faithful dependence on more than human guidance and strength, 
these efforts will never prove unsuccessful. 

669. But it is our more especial object to indicate the modes in which 
reciprocally the mind and body may promote each other's health ; and 
much may be summed up in the Platonic axiom that they should be w^ell 
balanced in their exercise and activity. The undue or too prolonged 
occupation of the mind with deep study or thought abstracts the supply 
of blood and of vital energies from the bodily functions : these suffer 
and fall into weakness and disorder, whilst the nervous system, the 
material organ of the mind, is ultimately exhausted by the continued ex- 
citement, and refuses to perform one of its manifold functions; hence 
stupor, paralysis, or organic weakness of some kind may ensue; or others 
may retain a morbid erethism or irritation in the midst of general weak- 
ness ; and delirium, spectral illusions, sleeplessness, tremors, spasmodic 
or painful affections may be the consequence. Mental idleness, on the 
other hand, not only weakens the intellect by disuse, but, by inducing 
habits of indolence and self-indulgence, pampers the body and perverts 
its proper functions, degrading them to an approximation to brutal or 
even vegetable life. Moderate and well-timed exercise refreshes the 
mental powers, and enabling them to apply with renewed vigor, increases 
their permanency and sphere of action. So likewise, pleasing men- 
tal impressions, as from beautifnl scenery, congenial associations, and 
interesting pursuits, heighten the benefits of bodily exercise, and give 
all the faculties that re-nascent energy which is well expressed by the 
term recreation. A similar advantage accrues from varying the kind of 
mental occupation; thus music, drawing, amusing games, and light 
reading, are to many, more effectual than absolute rest, in refreshing the 
mind after severe study or close application. In like manner, intellectual 
tasks of different kinds may be profitably alternated with each other, as 
the several muscles of the body are more beneficially exercised in suc- 
cession than all at once (§ 664). Analogous rules may be applied to the 
moral emotions, so far as they can be placed under the direction of the 
individual ; and there is in most energetic minds somewhat of a natural 



SLEEP — PROMOTING INFLUENCES. 



413 



or habitual succession of high and low spirits, of lights and shadows in 
the mental hemisphere, which, however trying and hazardous it may be 
in extremes, when occurring in moderation, gives a renewed vigor to 
thought which is wanting in minds of more perfect placidity. 

SLEEP. 

670. It would be quite superfluous to expatiate on the health-giving 
influence of a due amount of tranquil sleep. It is the chief means of 
recruiting the exhausted energies of the animal functions ; and some of 
the causes and consequences of its failure have been already noticed 
among the causes and elements of disease (§§ 23, 56, 64, 154). It ap- 
pears to consist in a more or less complete suspension of the cerebral or 
sensorial functions, with an increase of the medullary and organic nerv- 
ous influence; and we have suggested that a modification in the distri- 
bution of the blood through the nervous centres may be instrumental in 
thus periodically reducing the activity of those parts which are not so 
essentially concerned in the maintenance of life ( § 153). The sensorial 
functions are only impaired, not completely suspended, for a proof of their 
partial continuance during sleep is to be found, not only in dreaming, but 
also in the voluntary movements, often performed to remove uncomfort- 
able sensations, and even in the act of awaking when such sensations 
attain a certain degree of intensity. 

The approach of sleep is announced by the feeling of drowsiness, 
which consists of a dullness of sensation, perception, and thought, and 
an indisposition to exertion. Gaping and yawning, although symptoms 
of sleepiness, result from efforts to resist it : they seem to be movements 
designed to throw certain muscles, especially in the throat and neck, into 
a state of tension, during which the sensation of drowsiness is for the 
moment increased to a degree rather agreeable than otherwise, but fol- 
lowed by its diminution. It is very probable that these movements tend 
to re-excite the slackening cerebral circulation, by momentarily impeding 
it, and then allowing it to flow again with augmented force: a process 
like that of 'flushing . Sleep closes the relations of the senses to all mo- 
derate impressions of the external world, and suspends almost all volun- 
tary movements, among which are to be reckoned those supplementary 
to the process of respiration (§ 628). The respiration is therefore ren- 
dered less frequent and more prolonged than when awake, and the pulse 
is also lowered. The circulation and changes of the blood being thus 
reduced during sleep, there is less power of maintaining animal heat; 
hence the chilliness of persons during and after sleep, and their suscep- 
tibility to cold, unless better protected than usual by clothing. Hence, 
too, the relaxation of the skin after slight febrile excitement, which during 
sleep yields to perspiration. 

671. The circumstances which promote sleep are chiefly those which 
impair the activity of the animal functions, and those which withdraw 
all causes of excitement to mind or body. A moderate degree of bodily 
and mental fatigue ; the absence of all uneasy sensations ; a comfortable 
posture, giving the most comple rest to the limbs and voluntary muscles; 



414 



HYGIENICS. 



a freedom from the feeling of either hunger, thirst, or repletion, cold or 
heat ; the periodic recurrence of a regular hour for repose, and the still- 
ness and darkness of night, — are favorable for the induction of sleep. 
In addition to these, which act negatively by excluding excitement, there 
are others which are sometimes found to promote sleep by causing gentle 
and monotonous sensations or ideas which have the effect of lulling into 
somnolence: such, for example, as the various expedients for hushing 
infants to rest, by rocking, patting the back, singing, &c, and with adults, 
like soothing devices sometimes succeed ; as by gentle friction, reading, 
prosy talking, and other dull impressions on the senses which slightly 
tire without excitement. These probably operate by diverting the atten- 
tion from other feelings or noises, which occurring occasionally, tend to 
disturb. The passes of mesmerism seem to act on the same principle. 
The expedient of counting or reciting one's self to sleep owes its efficacy 
(which is but small) to the abstraction of all attention to an uninteresting 
object. 

672. The influences which prevent or disturb sleep are for the most 
part the reverse of those last described. Any undue excitement or 
sensation of body or mind, whether of a painful or a pleasurable nature ; 
strong, sudden, or startling impressions on the senses; uneasy postures; 
extreme fatigue or exhaustion; oppressed or imperfect breathing; palpi- 
tation of the heart ; hunger, thirst, nausea, flatulence, and various other 
(often undefinable) sensations in the viscera; extremes of temperature; 
coldness of the extremities; irregularity in habits of getting rest; — 
comprise the ordinary causes of sleeplessness. They operate either by 
directly exciting the sensorium to a degree inconsistent with the suspen- 
sion of its functions; or by so much reducing or disordering the power 
of the medulla, that it is incapable of sustaining the respiratory move- 
ments without the aid of voluntary effort. In the former case positive 
pain, uneasy sensation, or exciting trains of thought, are present. In 
the latter there may be the desire to sleep, but no sooner does its com- 
mencement suspend the voluntary efforts by which the breathing is aided, 
than this process becomes imperfect, and the person starts with a feeling 
of oppression or impending suffocation, which his commencing dream 
impersonates into nightmare, or connects with the idea of being pursued 
by demons, falling down a precipice, or some such horrible catastrophe 
which entirely precludes the reality of sleep. Such are the sleepless 
hallucinations of delirium tremens and similar disorders in which con- 
tinued excitement of the nervous system has exhausted the energy that 
is required in the medulla for the maintenance of respiration and muscu- 
lar tone during sleep. 

673. The loss of rest is so seriously detrimental to health, that to 
prevent it by hygienic means is of great importance ; and besides avoid- 
ing so far as possible the several causes of wakefulness just specified, 
bad sleepers should take heed to attend to the following directions for 
their regimen, rather than resort too hastily to hypnotic drugs, which, 
although sometimes useful and necessary as temporary expedients, lose 
their effect by habitual use, and produce other evil consequences which 
render their continuance improper. 

Bad sleepers should make a regular practice of early rising: it may 



SLEEP — PROMOTING MEANS. 



415 



cost them some trial of strength at first ; but if they would improve their 
sleep, they should seek it at the natural time, and not late in the morning 
when the excitements of the day begin. Their hours of meals and 
exercise should also be early and most regular (§§ 644, 662); both in 
order to promote that state of health most conducive to ease and freedom 
from suffering, and also to secure the accomplishment of the processes 
of digestion and consequent excretion or eructation before night, which 
is the proper period for repose (§§ 643, 4). Exercise should be used as 
freely in the open air as the strength will permit without causing lasting 
fatigue ; and if the strength do not bear walking or riding, driving or 
sitting out in the open air several hours in the day is an efficient means 
of promoting sleep by gradually and gently fatiguing the senses by the 
continued operation of light, air, and sound, whilst the organic energies 
are refreshed and invigorated by their salutary influence (§ 652). As the 
hour of retirement for rest approaches, every description of exciting 
agency should be avoided. The latest meal should be taken at least an 
hour before bedtime, and tea, coffee, and all vegetable matters apt to 
generate gas should be excluded from it. Weak persons and others 
under the influence of fatigue may often advantageously take a little wine 
or alcoholic mixture at this meal; its operation, which counteracts the 
exhaustion and nervous excitement induced by weakness, being compos- 
ing and hypnotic (§§ 64, 155). All active exertion of body or mind 
should be carefully avoided at this time. Subjects of conversation or 
reading should be common-place or tranquilizing, neither requiring much 
attention nor exciting to the feelings or imagination. The very prepara- 
tion of undressing should be simplified as much as possible, and all 
superfluous items or general washing, &c, should be postponed until the 
following morning. Much might be said about the construction of the 
bed and its appendages, and the posture best suited for tranquil repose; 
but this is not the place for such details, which may be comprised in the 
general direction that all is to be made as comfortable as possible, with- 
out relaxing by excessive softness or abundance of covering. A soft 
upper mattrass of hair, or wool and hair, is always preferable to a feather- 
bed, not only in being less relaxing, but also in its giving a more elastic 
and even support to the body and limbs, and preventing that sinking in 
of the body which fatigues a weak back by bending it. The posture most 
easy for the person is on the right side, which affords to the two weightier 
organs, the liver and heart, support which prevents them from pressing 
on the hollower viscera. The various expedients for inducing sleep by 
repeating lines of poetry, counting and numbers, and other means which 
act by diverting attention from exciting trains of thought, seldom succeed 
with the really wakeful. The plan devised by the late Mr. Gardner, and 
published by Dr. Binns in his "Anatomy of Sleep," (p. 391,) has not 
proved more successful in my experience. It is founded on the same 
principle of abstracting the attention, by directing the mind to the ima- 
ginary vision of the breath issuing from the mouth during expiration. A 
device which I have found to answer better, is founded on the attempt to 
imitate the mode of breathing of a person during sleep, by making the 
respirations, particularly the expirations, lower and more prolonged than 
usual, and giving to them somewhat of a sonorous character from the 



416 



HYGIENICS. 



relaxed and therefore imperfectly open state of the glottis. This often 
excites a feeling of drowsiness, probably by gently retarding the return 
of blood from the brain ; and this drowsiness may soon end in sleep ; but 
it frequently happens with this, as with all other voluntary attempts to 
procure sleep, that the continuance of the effort breaks the spell by the 
awakening effect of excited attention, and this objection especially applies 
to the first attempts to practise such invocations of Morpheus. The ex- 
pedient recommended by Dr. Franklin to restore sleep that has been 
broken, by rising and shaking the bed, with the view to change its air, 
is sometimes successful, particularly in hot weather. 

674. The amount of sleep most conducive to health varies consider- 
ably with age, sex, employment, and constitutional and habitual pecu- 
liarities. Infants pass the greater part of the day as well as the night 
in sleep ; and children, up to the age of six years, generally require at 
least twelve hours of repose, besides an hour or more in the middle of 
the day. At about this age, the sleep at noon may be discontinued, but 
the night sleep can hardly be abridged with advantage, until about the 
tenth year, and then only to a moderate extent, until the period of 
puberty, after which it is generally proper gradually to reduce the period 
of rest to nine or ten hours; and no further diminution is expedient until 
the cessation of growth, when another hour or two may be taken from 
it. The average amount of daily sleep beneficial in adult and middle 
ages may be stated at eight hours. In more advanced life this extent 
of sleep is not less serviceable where it can be procured ; but at this 
period the capacity for sleep usually diminishes, and wakefulness or dis- 
turbed sleep, is a common complaint of old age. Attention to the pre- 
cautions before recommended (§ 673) will, however, often restore it; and 
even if they do not sleep, aged persons require an increased period of 
time in bed, for the sake of warmth and rest, which their reduced calo- 
rific and muscular powers render more necessary. 

Females commonly stand in need of more sleep than males, and during 
pregnancy and lactation additional rest is especially demanded, to assist 
the supplementary nutritive processes brought into operation in these 
conditions. In such cases, too, the loss of sleep is attended and followed 
by peculiarly injurious results, manifest especially in the nervous system 
and general nutrition, in the form of mental derangement, impaired vision, 
deafness, paralysis, palpitation, cunvulsions, tremors, anorexia, wasting, 
diarrhoea, &c. Under these circumstances, a chief object of the treat- 
ment will be to procure sleep, and in addition to regimenal means before 
suggested, nervous sedatives or hypnotics of the least depressing kind 
are required. Persons convalescent from acute diseases, or otherwise 
weakened and reduced, require and generally obtain more sleep than in 
ordinary health, and it is so efficient an influence in the promotion of 
recovery, that artificial means are sometimes properly used to procure 
it. So, likewise, those who use much active exertion need a longer 
period of repose than those who are sedentary; and the same rule is ap- 
plicable to persons whose minds are greatly exercised ; but as mental 
excitement does not dispose to sleep to the same degree as bodily fatigue, 
it is the more important that all persons whose intellectual powers are 



EXCRETION. 



417 



much strained, should also use such exercise as may maintain the balance 
and promote the return of sleep. 

675. Salutary as is the operation of sleep in its due time and degree, 
it may prove injurious if indulged in to excess and at improper seasons. 
Too much sleep slackens the circulation, diminishes excretion and mus- 
cular nutrition, and causes general plethora or partial congestions, and 
in those disposed, promotes the accumulation of fat. By inactivity it 
weakens the muscular and sensorial powers, and gives an ascendency 
to the medullary function: hence a tendency to spasmodic and other 
nervous disorders of the system, which may further declare themselves 
in fits of hysteria or even epilepsy. In persons liable to this class of 
disorders, a judicious abridgment of sleep is often very beneficial; and 
it is best effected by gradually establishing the habit of early rising. 
Undoubtedly the most fitting time for sleep is the night, and although in 
these latitudes the nights are in summer too short, and in winter too 
long for the amount of needful repose, yet the more nearly this is assigned 
to the period when darkness and silence warn to rest, the better for the 
permanent comfort and well-being of the body. On the score of health, 
then, it is recommended that even adults should retire to rest, in summer 
especially, as many hours before midnight as can be spared after night 
closes ; in order that they may be enabled to rise at or as soon after sunrise 
as they have had their proper complement of sleep. But, inasmuch as the 
usages of society and the business of life often make unavoidable demands 
on the night hours of many persons, the compromise of retiring one hour 
before midnight should be enjoined for the sake of health, and accompa- 
nied with an exhortation to early rising, enforced by a description of the 
refreshing and invigorating influences of the morning air, with all its 
exhilarating concomitants of light and sounds. 



EXCRETION. 

676. The absolute necessity of a sufficiency in the processes of excre- 
tion for the maintenance of health, has been made apparent by the nu- 
merous instances cited in the preceding pages, in which their failure 
has led to the production of disease (§§ 68, 248 — 254, 385, &c.) ; and 
although such instances commonly constitute such cases of disease as 
require the application of medicinal means, yet the regularity and com- 
pletion of the processes of elimination may be so far promoted by common 
regiminal measures as to deserve a place among hygienic elements. 
Depending, as excretion does, on the activity of the processes — of cir- 
culation, which regulates the supply of blood to the secreting organs ; 
of respiration, which improves the properties of that blood by renewing 
its chief chemical agent, and of assimilation, which adds to its materials; 
of muscular contraction, which effects the expulsion of the excremen- 
titious matter; and of sensation, which takes cognizance of the need of 
its evacuation — it might be anticipated that the proper performance of 
this office (excretion) will much depend on the vigorous condition of 
these several processes, which with it compose the sum of the general 
health. Hence many of the hygienic measures that have been recom- 
27 



418 



HYGIENICS. 



mended as contributing to sustain these several processes, are likewise 
efficient in promoting that of excretion. Thus a proper regulation of 
food, solid and liquid (§§ 642 — 644), and a regular use of exercise 
(§§ 660 — 662), are important means of favoring all the excretions; and 
the functions of the skin and kidneys, and, in less degree, those of the 
liver and intestines also, are influenced by clothing, temperature, air, 
and sleep (§§ 646—649, 652—655). 

It will be sufficient to indicate a few of the more available means 
which are found useful in regulating the actions of the bowels, kidneys, 
and skin in health. 

677. No circumstance tends more to promote the regular action of the 
intestines, than tjie punctual habit of daily devoting a fixed and sufficient 
time to their evacuation. Medical writers have long insisted on the im- 
portance of punctuality in attention to this office; but they have not 
recognized the necessity of dedicating an amount of time sufficient for 
its proper completion, yet with persons of costive habit this is not a 
secondary consideration. In persons whose bowels act readily, an effi- 
cient peristaltic action forwards the feculent matter in consistence and 
quantity fitted for prompt and easy expulsion at the accustomed time ; 
but with those of torpid bowels (and they constitute a very numerous 
class, even among healthy persons), the excrement is more solid and the 
intestinal movement more tardy, and instead of being all in the rectum 
ready for delivery at the appointed hour, more or less of it may be still 
lagging behind in the sigmoid flexure, or even above it, and cannot be 
discharged by a momentary effort. Nor will violent straining (which 
is, moreover, injurious in other respects (§§ 64, 289), properly aid in the 
process. Repeated gentle and sustained abdominal contractions, aided, 
if necessary, by kneading pressure or friction downwards in the left 
iliac region, in the direction of the sigmoid flexure, with some variation 
in the position of the trunk, are the safest and most efficient means of 
accomplishing this object, but they require the sacrifice of a few minutes 
of time ; and if the end were not worth this sacrifice, I would not shock 
the delicacy of my readers by allusion to so disgusting a subject. 
These expedients are more easy and natural, and less injurious than the 
use of enemata; of which even the simplest kinds, if employed habitually, 
injure the tone of the bowel, and impair its natural action. 

678. Other means may be mentioned as serviceable in ordinary health 
to promote a regular and sufficient action of the bowels, such as the use of 
brown or rye bread, instead of white; taking at night oatmeal porridge; 
ervalenta or lentils ; white mustard seed ; stewed prunes ; tamarinds ; 
baked apples,[and the like; all of which act by adding either a mechani- 
cal or a chemical irritant to the feculent mass, and may prove objection- 
able by irritating too much and otherwise disordering the alimentary 
canal. The same objection applies to the addition of toasted bacon to 
breakfast, and that of a quantity of fruit to dinner. A more harmless, 
and sometimes more efficacious expedient, is that of drinking a large 
draught of cold spring water at first rising, which is useful for other 
purposes likewise. With some persons malt liquors promote the action 
of the bowels. A walk before breakfast for the more robust, or a walk 
or ride immediately after that meal for others, often contributes to the 



EXCRETION — URINE. 



419 



same end ; and in some instances such exertions as particularly bring 
into action the abdominal and other muscles of the trunk, such as digg- 
ing, or other occupations in gardening, prove more effectual. 

679. Lastly, we must not omit mention of the habitual use of gentle 
aperient medicines, as the safest and most efficacious means of securing 
an adequate intestinal action in persons whose sedentary occupations or 
other circumstances absolutely prevent their adopting more strictly 
hygienic measures for the accomplishment of the same purpose. Un- 
doubtedly, it is preferable to avoid the constant use of medicine, if diet- 
etic or regiminal management can be so conducted as to supersede it ; 
but much observation has convinced me that this cannot always be 
effected, and then as a prophylactic or hygienic resource, a little daily 
pill is preferable to the practice of loading the stomach with indigestible 
matter with the object of stimulating the lower bowel. The drugs which 
commonly answer best as habitual laxatives, are rhubarb and aloes, both 
of which in their bitter properties combine somewhat of a tonic with 
their aperient action. Aloes is the most efficacious aperient, and if 
properly managed, does not lose its effects, even after many years of 
daily use. I know of an instance in which it was continued for fifty- 
seven years with unquestionably beneficial results, and the individual, in 
spite of very sedentary habits, retained uncommon vigour of body and 
mind until within a year of his death, which occurred at the age of 
eighty-seven. By far the best mode of administering aloes as a habitual 
aperient, is in combination with a little mastich, and made into a mass 
with alcohol, which renders the pill less soluble in the stomach, and, 
therefore, more capable of acting on the lower part of the canal. The 
combination which I commonly use, consists of three parts of socotrine 
aloes, with one of mastich powder, made into a mass with alcohol ; two 
or three grains of this are to, be taken at dinner or at bed-time daily. 
This pill has no tendency to excite hemorrhoids, provided an occasional 
dose of blue pill be taken to promote a sufficient action of the liver. In 
several instances I have found it operate more comfortably on joining 
with it a few grains of inspissated ox-gall. In weakly persons, a grain 
of sulphate of iron or quinine may be added with advantage. 

680. The excretion of urine is less generally an object of solicitude 
than that of alvine function, yet it is remarkable how usually persons as 
they advance in years have their attention drawn to it, often from experi- 
encing the discomforts of its irregularity or deficiency; and such irregu- 
larities are undoubtedly an important element in a vast proportion of 
diseases, whether serious or trivial. It would occupy too much time to 
advert at length to disordered excretion of urine here; in fact, the sub- 
ject has been considered in almost every part of the present work; and 
it must suffice to mention a few common hygienic influences by which 
the urinary excretion may be promoted or rendered more free. 

The abundance of urine, and therefore usually its clearness and 
moderate specific gravity, will be generally proportioned to the amount 
of fluid ingesta; but the increase is more sure, when fluid, especially 
water, pure, or with a very slight addition of vegetable or animal nutri- 
ment, is taken on an empty stomach. Thus, a large draught of spring 



420 



HYGIENICS. 



water drunk at first waking in the morning, or an hour before dinner, is 
almost surely followed by a free flow of clear urine. This result is pro- 
moted by such moderate exercise as excites the heart's action without 
causing free perspiration. Some kinds of exercise peculiarly augment 
the secretion of the kidneys; especially those bringing the loins into ac- 
tion, as gardening, and trotting on horseback ; and these modes of exer- 
cise may therefore be recommended to those whose secretion is defective, 
especially those liable to lithuria ; for by increasing the watery constituent 
of the urine, there is less risk of any deposit taking place in the urinary 
apparatus. But similar means, if regularly used, are useful also in 
gouty and rheumatic habits; and they appear to establish an increased 
elimination of solid matter, as well as of water, by the kidneys; and in 
this respect their operation differs from that of medicinal diuretics, which, 
unless very judiciously administered, excite for the time, and leave the 
secreting power exhausted afterwards. This is the chief objection also 
to certain diuretic beverages in common use, but as temporary expedi- 
ents they are useful; such as gin, Hollands, or whisky, diluted with 
water; spruce beer; imperial drink (water saturated with bi-tartrate of 
potass, sweetened and flavoured), leek or onion broth, barley-water, lin- 
seed and tamarind tea, Seltzer water, &c. Grapes, currants, and other 
ripe sub-acid fruits, also may be occasionally useful in the same way. 

681. The regular evacuation of the bladder, when distended to a cer- 
tain degree, is prompted by the sensation excited, but in very various 
degrees in different individuals; some, either not feeling or resisting the 
want, and others yielding too frequently to its impulses. The latter ex- 
treme is inconvenient, especially from its disturbing sleep at night ; but 
the habit of too long retaining the urine may prove pernicious in various 
ways formerly specified (§ 68), and should therefore be carefully avoided. 
In circumstances interfering with a proper observance of this caution, 
its urgency may be diminished by limiting the amount of liquids taken, 
and by promoting the cutaneous excretion by warm clothing and external 
warmth. 

682. The full purposes of the perspiratory secretion are not entirely 
known ; but its uses are recognized, — in evacuating from the superficial 
vessels superfluous water, acid, and oily matter, under the distending or 
exciting influence of prolonged heat or exertion; intending by its evapo- 
ration to cool the surface thus heated, and by its relaxing effect on the 
tissues to remove the irritation of distention or obstruction ; and by the 
same softening operation to render the skin more pervious to the chemical 
action of the air on the blood, and to the vital influences reciprocated 
between the blood and the tissues. 

The excretion of the skin has been mentioned to be materially in- 
fluenced by clothing, exercise, and temperature and air, and these are 
the chief means by which it is variously affected in healthy persons. 

Other hygienic measures for promoting the action of the skin, are 
bathing, washing, and friction. The chief operation of all these agents 
is on the skin, as an instrument of circulation and secretion; and in 
proportion as they are extensively applied, they may exercise an influence 
on the whole system. Thus warm bathing of the whole body, as it in- 



HYGIENIC RULES FOR THE SICK. 



421 



creases the amount and motion of the blood in the cutaneous vessels, and 
the perspiration from them diminishes the supply to internal organs, and 
consequently the amount of their secretions. If continued long, or re- 
peated frequently, general weakness will result, the surface remaining 
in a relaxed state. The same objection does not apply to the occasional 
use of the warm bath, or the daily practice of washing the whole surface 
with tepid sponging or shower-bath, followed by friction; and these are 
highly salutary means of keeping the skin in a free and active condition 
well suited to persons of languid circulation. But, in the majority of 
healthy subjects, this object is better obtained by cold washing, and in 
the robust, even by cold bathing, in shower or plunge, which indirectly 
excites the functions of the skin by constricting its vessels, and thus 
throwing the blood on internal organs, and by impression on the inci- 
dent nerves, causes the excitement of reaction, which soon restores 
the superficial circulation in redoubled force, with its concomitant red- 
ness and glow(§ 80). This reaction is much promoted by vigorous fric- 
tion of the whole surface with coarse towels or horse-hair gloves, and 
this operates not only by stimulating the cutaneous vessels and glands, 
but also by the muscular exertion exciting the heart to stronger and 
more frequent contractions ; for the same reason, other exercise, as in a 
brisk walk, is often useful. If after cold bathing the reaction is incom- 
plete, and the skin remains pallid, chilly, and contracted, it may be in- 
ferred that the cold has been too long applied, and has permanently im- 
paired the functions of the skin, and left the internal organs more or less 
congested. Or, if, after complete reaction, an unpleasant fatigue, languor, 
chilliness, headache, or other uncomfortable sensation remain, it is a 
proof that the cold and subsequent reaction have been too depressing or 
exhausting; in either of these cases tepid bathing or washing is to be 
preferred. The vapor-bath, with shampooing and various aromatic and 
stimulant applications, although a powerful remedial agent in cases of 
disease (especially chronic rheumatism and its consequences), is too ex- 
citing and exhausting to be recommended as a means of preserving 
health. 

[683. A few general rules on the hygienics of sick persons will not 
inappropriately close this chapter. 

Patients laboring under acute disorders should be placed in large, dry 
and well ventilated apartments. The temperature of the room should 
be equable and moderate; the amount of light must be regulated by the 
character of the disease. When the air is contaminated by noisome ex- 
halations, fumigations may sometimes be advantageously resorted to. 
If the room in which the patient is taken ill be small, badly ventilated 
or damp, he should be removed, if possible, into a larger one, free from 
these inconveniences, as the risks of moving, even in severe febrile af- 
fections, are less than is usually imagined. (Chomel.) 

684. Great cleanliness should be strictly maintained, and for this pur- 
pose the linen should be frequently changed ; but not so as to fatigue the 
patient. It may be done even whilst the patient is sweating copiously, 
and great comfort will result. To effect this, warm cloths, passed un- 
derneath the shirt, should envelop successively the legs, thighs, abdomen, 



422 



HYGIENICS. 



chest, and even the neck, so that the arms alone will be momentarily 
exposed to the air. Patients should never be permitted to sleep on 
feather beds, without an intervening mattrass. It is often necessary to 
employ auxiliary means to receive the excretions, impermeable cloths to 
protect the bed linen, and cushions to obviate pressure on certain parts 
of the body. The position of the bed should vary according to the 
nature of the disease. 

685. The employment of suitable aliments and drinks in acute affec- 
tions is of great importance, and adds materially to the comfort of the 
patient. There are two extremes to be equally avoided; nourishing 
patients too much, and not nourishing them enough. Hippocrates thought 
it safer to err on the side of excess, than for patients to observe total ab- 
stinence. In acute febrile affections, you should observe a just medium. 
Proscribe all kinds of solid aliment, but permit the use of fluids slightly 
nutritious, such as farinaceous articles, light broths of veal and chicken, 
the juicy fruits, etc., when the febrile movement is not too high. In the 
low forms of fever, when the strength has to be supported, it is indis- 
pensable to nourish the patient, and severe adynamic symptoms may 
often be prevented by timely nourishment. The injudicious use of food 
has the power, it has been remarked by a celebrated authority, of nour- 
ishing the disease, and not the patient. 

686. It is of immense importance in all acute disorders that the ex- 
cretions of the patient should be immediately removed. Perspiration 
chills the body; the urine and fecal matter, already compromised, are 
disposed to speedy decomposition, and impart noxious qualities to the 
air. When involuntarily excreted, their contact with the body is posi- 
tively injurious, by provoking eruptions, excretions, and even sloughing. 

687. In acute diseases, repose and quiet are indispensable. Syden- 
ham thought that fever patients should be made to rise every day, and 
that doing so obviated the tendency to delirium. There is no doubt but 
that patients should be daily placed in an arm-chair, or on a bed, accord- 
ing to their strength, in order to allow their own bed to be made ; if this 
cannot be done, they can be removed to another portion of their bed, 
whilst the necessary change is made. When a patient is too feeble to 
change his position in bed, it should be done for him frequently; it adds 
materially to his comfort, prevents the formation of sloughs, and obviates 
the tendency to pulmonary congestion, so frequent in protracted fevers. 

688. Sleep is generally a favorable symptom in acute diseases. Every 
thing which, by acting on the senses, or the moral of the patient, will 
prevent it, should be obviated. From the same motives sleep should not 
be broken to administer medicines, without the necessity is urgent. 
Sleep may sometimes be induced in convalescence, by causing the 
patient to rise, and re-adjusting his bed. Gentle friction w T ith the fingers 
on some part of the body disposes to somnolency. 

689. The sensations, the emotions and intellectual faculties all de- 
mand, in a special manner, the attention of the physician. The removal 
of all moral or mental circumstances, which either have produced or 
keep up the morbid condition, is important. Conversation should be 
banished from the sick chamber; when low, it is annoying; when loud, 
fatiguing and exciting. The influence of the passions of the mind 



HYGIENICS FOR THE SICK. 



423 



is so great that nothing should be neglected to give them a favorable 
turn. To this end the physician should obtain and deserve the con- 
fidence of the patient, (careful attention and great interest will frequently 
accomplish this,) and he should be careful that nothing in his manner or 
speech should betray anxiety or uneasiness. Patients generally receive 
with satisfaction assurances of the successful termination of their com- 
plaint from their physician. The fear of death adds materially to the 
danger, in a majority of instances, and "the physician," says Chomel, 
" who allows his patient to suspect the danger of his position, diminishes 
his prospects of recovery." Sir H. Halford, in some judicious remarks 
on the duty of a physician, in withholding from, or communicating to, a 
patient the probable issue of a disease displaying mortal symptoms, says, 
"that the first duty of a physician is to protract the life of a patient by 
all practical means."* The probability of a fatal issue should, therefore, 
be communicated to the friends, and, except under very peculiar circum- 
stances, never to the patient. 

690. In chronic diseases, hygienics are of immense utility. Change 
of habitation and climate, voyages by land and sea, a sojourn at some 
fashionable watering-place, &c, often succeed in restoring health when 
all other remedial measures have failed. — C] 



* Lond. Med. Gaz., vol. vii. p. 602. 



APPENDIX. 



THE PATHOLOGY OF GOUT AND ALBUMINURIA. 



In addition to the facts mentioned in Sections 13 and 14 of Chap. II., 

I may state that Dr. Garrod has, in several other cases of gout, detected 
lithate of soda in very appreciable quantity in the blood, whilst at the 
commencement of a fit of gout there is a marked diminution of it in the 
urine. On the abatement of the attack, the lithic acid, or its compounds, 
appears in increased quantity in the urine, and that in the blood is there- 
fore diminished. This exactly accords with the view that I have always 
taken of the nature of acute gout in common w r ith other febrile diseases 
excited by a morbid matter in the blood, that the febrile excitement is 
the result of a reaction which may succeed in eliminating the offending 
matter, and in relieving the system from its influence (§§ 254, 448). 
It appears further, from Dr. Garrod's analyses, that slight traces of lithic 
acid may be detected in the blood of persons who are comparatively 
healthy, or who are affected by other diseases than gout ; but in this 
malady the amount is much greater. My clinical assistant, Mr. Edward 
Palmer, (on whose accuracy I can fully depend,) has separated crystals 
of lithic acid also from the blood of two of my patients suffering from 
degeneration of the kidneys with albuminuria. In acute rheumatism, 
Dr. Garrod found no increase of lithic acid in the blood ; but I have little 
doubt, from its abundant appearance in the urine in many cases during 
the decline of this disease, that something analogous and easily convert- 
ible into it, does exist in the blood of rheumatic patients, and that further 
researches will establish the chemical relation between two diseases 
which are known to border so closely on each other, in regard to their 
symptoms and treatment. 

Some of the above-mentioned researches, and others made expressly 
by Mr. Palmer, have further illustrated the pathology of albuminuria, as 
explained at § 385. In the case of a female, the urine voided in twenty- 
four hours amounted to 20 oz. sp. gr. 1018, containing albumen, mea- 
suring when coagulated three-fourths of the depth of the urine in the 
tube. The w T hole amount of solids did not exceed 372 grains, of w T hich 
88 grains w r ere albumen, and 140 urea. The patient died comatose five 
days after, and lithic acid, as- well as abundance of urea, was found in 
-the blood. In another case the whole amount of urea excreted in twenty- 



THE CAUSES AND TREATMENT OF SCURVY. 



425 



four hours did not exceed 103 grains, whilst no less than 416 grains of 
albumen were passed. 

The following table represents the amount of solids contained in the 
urine of a woman admitted into the hospital with recent anasarca and 
albuminuria, and treated by the remedies mentioned in § 395. 

Solids in Urine. 

Nov. 4th . . 597 grains. — At this date the albumen half-filled the tube. 
5 . . 565 — 

8 . . 589 — 

9 . . 934 — 

.j g C Anasarca now removed ; and albumen disappeared 

2_ from the urine. 

17 . . 710 — 

18 . . 1041 — 



THE CAUSES AND TREATMENT OF SCURVY. 



Except a brief allusion in § 63, little has been said in the text on the 
nature and treatment of scurvy ; and this was because the subject re- 
mained involved in much obscurity, and had received little light from 
pathological research. A paper has been just published by my colleague 
and former pupil, Dr. Garrod, which propounds a view of the real cause 
of the disease which is at once so plausible, and so directly suggestive 
of a simple and effectual remedy, that it deserves notice in this place. 
On carefully comparing the kinds of food, the use of which have been 
observed to be followed by the occurrence of scurvy, with the dietetic 
and medicinal articles which have best repute as being antiscorbutic, 
Dr. Garrod found the former to be remarkably deficient in potash, whilst 
all the latter contain it in considerable quantity. Thus, on analysis, he 
found oatmeal, rice, peas, white flour, cheese, and salted meat, to contain 
much less potash than potatoes, fresh meat, milk, and the juice of limes, 
lemons, and oranges, which are reputed to be antiscorbutic. He further 
discovered in the few scorbutic patients whom he had the opportunity of 
seeing, a marked deficiency of potash in the blood or urine; and the 
treatment by a few grains of a salt of potash was followed by speedy 
recovery. Dr. Garrod considers that potash is essential as a normal 
constituent of muscular structure, and that its nutrition must fail when no 
longer supplied with this alkali. "Both soda and potash are constant 
constituents of the animal body, and it appears that they are not capable 
of replacing each other; for example, we always find the potash to exist 
in large quantities in the ash of muscle, and soda in very small quantities 
(Berzelius, Liebig) : in the ash of blood we find the relation reversed. 
It appears also that the muscular system requires the presence of potash, 
and we should therefore expect to find that when there is a deficient 
supply of this base, the effect would soon be manifested in the functions 
of that system. This we find to be the case in scurvy; without any 
amount of wasting of the body, we find marked muscular debility, and 
this is perhaps one of the earliest symptoms of the disease." (Monthly 
Journal of Medical Science, Jan. 1848.) I may add, that the fatty de- 
generation of the muscles (§ 545) has been observed to occur in pro- 



426 



ON THE USE OF CHLOROFORM. 



tracted scurvy, probably from the same want of this normal constituent 
of muscular tissue. 

Should this ingenious theory be confirmed by subsequent research, it 
may prove of great value in its application to practical medicine, not in 
the treatment of scurvy only, but in other diseases attended with muscular 
debility, and a disposition to passive hemorrhage. It may be remarked, 
that in Mr. Blake's experiments, the salts of potash in solution injected 
into the veins, caused a firm coagulation of the blood, whilst those of 
soda had a contrary effect (§ 214, note). The bitartrate of potash, too, 
is reputed to be a remedy for hemorrhage. 



ON THE USE OF CHLOROFORM. 

The important discovery by Dr. Simpson of the power of the vapor of 
chloroform, as an anodynizing agent when administered by inhalation, 
in the same mode as the vapor of ether, was made since the greater part 
of this work was printed, the subject being only briefly noticed at page 
427, note. Extensive trials have clearly proved it to be more potent than 
ether in suspending sensibility during surgical operations, painful attacks 
of a spasmodic character, and during parturition, and in some respects 
to be attended and followed by less injurious effects. Its use will, there- 
fore, probably in great measure supersede that of ether. Bat there is 
one part of its operation, which, although recommending it in some in- 
stances, might render its use hazardous in others. It seems generally to 
lower the pulse, and, according to my experience, often leaves consider- 
able debility and depression of spirits after its use. In cases of much 
exhaustion, therefore, it would seem less eligible than ether, which has a 
more stimulant action ; and in all cases in which its influence is required 
to be sustained for any length of time, great circumspection should be 
used in its administration, by constant attention to the state of the pulse, 
and by withdrawing the inhaler so soon as sensibility is sufficiently re- 
duced to avoid pain. It appears to me that the object to be sought is 
freedom from pain rather than profound insensibility, and it is obvious 
that this result can be obtained at much less risk to respiration and cir- 
culation than that degree of narcotization which, in abolishing all the 
cerebral functions, encroaches also on some of those of the medulla, and 
may thus endanger life. The fatal case which has recently occurred in 
Durham,* as well as various experiments on animals, show that death 

* Dr. Simpson has endeavored to show (Lancet, Feb. 12, 1848) that death was caused 
in this case, not by the chloroform, but by the brandy administered to restore animation, 
and which, there being inability to swallow, passed into the larynx, and caused asphyxia. 
The appearances after death were undoubtedly those of asphyxia, with fluid blood in the 
right cavities of the heart; whereas in animals poisoned with chloroform, the blood is found 
coagulated. (Dr. Bennett, Monthly Journal of Med. Science, Jan. 1848.) That the insen- 
sibility induced by the chloroform favored the occurrence of asphyxia, I think, however, 
is proved, by the absence of cough on the administration of the brandy. Even in weak 
persons, so long as the medullary function is active, any stimulant applied to the glottis 
would excite violent coughing, which would expel the offending matter. Here, then, is a 
reason for not pouring any liquid into the mouth of a person in the state of insensibility. 



ON THE USE OF CHLOROFORM. 



427 



may result from the undue operation of this agent. It is only reasonable 
that it should take its rank with opium and other potent drugs, which are 
remedial or poisonous according to the doses and condition of the system 
in which they are exhibited. 

In one respect the insensibility from chloroform or ether differs from 
that from opium and other powerful narcotics : the sopor comes on rapidly, 
and ceases quite suddenly, so that the senses are regained all at once, 
as after a deep sleep, and the person is quite free from all drowsy feel- 
ings. Now, although this transient duration of the sopor may be partly 
ascribed to the agent in a volatile state being easily dispersed, yet it 
also seems to indicate that the suspended sensorial function resembles 
profound sleep rather than coma, and perhaps depends on a partially 
interrupted circulation through the brain (§ 670). 



THE 



STUDY OF GENERAL PATHOLOGY, 

THE 

PROPER FOUNDATION OF PRACTICAL MEDICINE. 



Extracted from an Introductory Lecture on the Principles and Practice of Medicine, 
delivered at University College, Oct. 1, 1842. 



[The following extracts from an introductory lecture were prefixed 
to the first edition of this work, and they are appended to the present, 
not only to explain the relations which the subjects of this volume bear 
to other departments of medical knowledge, but also to repeat to the 
profession a statement of what the author considers to be the true reasons 
why practical medicine has not fully profited by the advancement of 
science, a question which has recently been discussed with much ability 
by Drs. Forbes, Combe, and others.*] 

State of Practical medicine, as a study, and as an art. — Favor shown 
to empiricism by the public. — Irksome and difficult character of the 
study of medicine as usually taught. — Insufficiency of empirical and 
nosological medicine. — Some knowledge of general pathology at 
length gained in practice. — Need of general pathology in the study 
and practice of medicine. — What is general pathology 9 — Its contri- 
butions from all departments of medical science, especially clinical 
medicine. — General pathology the proper introduction to special pa- 
thology. —Where principles fail, experience must be the sole guide. — 
Noble nature and objects of medicine the best encouragements to its 
careful study. 

I must further state another circumstance which makes me especially 
anxious to use my best exertions in teaching the subjects of my course. 

* Most of these writers appear to me unduly to depreciate British medicine, which can 
scarcely be said to be truly represented by the class of either practitioners or publications 
which have led to a sweeping condemnation of the whole system, and to revolutionary 
demands for a "Young Physic." On these subjects I would record my entire concurrence 
with the sentiments expressed by my able and excellent friend Dr. Symonds, of Bristol, 
whose letters (British and Foreign Medical Review, Oct. 1846, April 1847) I particularly 
recommend to the attention of the reader. 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



429 



It is, the low position which this most important part of medical science 
still holds with the public, and even with students. I feel this to be a 
matter of such moment, that, with the hope of rescuing it from such un- 
merited depreciation, I propose to make the chief subject of this lecture, 
the state of practical medicine, as a study, and as an art. 

Compare the state of the practice of medicine with that of anatomy, 
physiology, and chemistry, — the great fundamental or preparatory studies. 
How minute, how precise, how connected and definite, are these! Yet 
how loose, indefinite, uncertain, unconnected, is the practice of our art! 
To the public it appears altogether vague — without any acknowledged 
principles. 

Is there any wonder, then, that quackery should triumph ? that the pub- 
lic show their want of faith in legitimate medicine by their ready belief 
in any novelty that is not legitimate ? Thus, one year, St. John Long's 
plan; another year, homoeopathy; another, Morison's pills; another, the 
water-cure, — rules the fashion. The public may show their ignorance 
by such credulity; but they show also the want of something plain and 
trustworthy in regular medicine. The public will not believe that the 
secret of the art is with a faculty which professes to follow experience 
only. The quack also can appeal to his experience; and that too, in a 
way more striking and convincing than those who express doubts and 
admit difficulties. Thus, one who cures nervous diseases can calculate 
his success by the numerical method. In eight thousand cases he can 
count only twenty failures. Another tells you of an extraordinary per 
centage of success in cases of deafness, in which the most eminent prac- 
titioners had failed, &c. Hence you will find the partisans of quackery 
far more zealous in the defence of their favorite notions than others are 
in support of the regular art. No wonder that homoeopathy and the 
w T ater-cure have their royal and noble advocates. Then there is a cap- 
tivating simplicity in the theories of quacks. A certain high official per- 
sonage pins his faith to an empiric who was formerly a gardener, and 
whose notion is, that all diseases proceed from buttercups. This is the 
theory: every man, woman, and child, eats mutton, beef, or butter, or 
drinks milk • every cow and sheep eats buttercups with its grass ; butter- 
cups are rank and acrid weeds; ergo, all diseases proceed from butter- 
cups. How beautifully simple! How attractive, too, are the comprehen- 
sive views of the hygeist and the water-curers! They both agree in 
their pathology ; all diseases arise from bad matter in the blood; they 
only differ in their mode of expelling it from the system. One purges 
out the peccant humor; the other washes and sweats it forth. There is 
something, too, very fascinating in the notions of homoeopathy: similia 
similibus medentur. Who cannot fail to admire the expansive genius of 
Hahnemann, who discovered that the best cure for a disease is the influ- 
ence which caused it ? 

On the other hand, the regular practitioner has nothing so plausible 
or so captivating to bring forward in explanation of his method. He 
either has no theory at all, and grounds his practice on experience, (in 
which we have said he is matched by the empiric,) or, if he gives a 
theory, it is viewed only as an opinion no better than the hypothesis 
of the quack, in an art so little founded on principles as medicine. So 



430 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



little favor does medicine receive from the public in its pretensions to 
science! 

How is it with the student? Surely the practice of physic must be 
as interesting as it is important to the student — the useful application of 
all his knowledge — the winding-up of the drama of his studies — the re- 
hearsal of the great performance of his life. Surely this must be a very 
attractive study? Quite the contrary. I believe it has been generally 
considered by students as the heaviest, most repulsive, most tedious of all 
subjects, (with, perhaps, a single exception.) Without the constant 
appeal to the senses with which anatomy attracts and rivets attention ; 
without the beautiful connections and adaptation of means to ends which 
make physiology interesting : without the simplicity and striking phe- 
nomena which give a charm to chemistry, the practice of medicine, as 
taught, is an enormous mass of dry detail; its science, mere glimpses 
into an unknown land ; its rules, irregular tracks through a wilderness 
of confusion. Practical medicine is studied only from a conviction that 
it is useful and necessary; and not because it is easy or agreeable. 

Further, there are a great many students, certainly not the most indus- 
trious, who shirk the disagreeable duty, pleading that it is neither useful 
nor necessary; and that the practice of medicine is only to be learnt at 
the bedside, with whatever aid books can supply. It would speak more 
in favor of this opinion, if its advocates acted up to their dogma, and 
proved, by their constant and diligent attendance in the wards of the 
hospital, that they seek there the knowledge which they profess to be 
unable obtain in the lecture-room. But, so far as my observation has 
gone, I do not find this to be the case. It is not those that neglect the 
lectures, but those who most regularly attend them, that prove to be at- 
tentive students in the hospital. 

But, although useful and necessary, it cannot be denied that the study 
of the practice of medicine, both by books and by lectures, is at first very 
difficult and irksome — more so than other studies. But why is it so ? 
This is a serious matter. Let us examine a little into it. Is the fault 
in the imperfect state of the subject, or in the method by which it is 
taught ? The science of practical medicine is undoubtedly very imper- 
fect ; but I think it can be shown that there is a still greater imperfection 
in the method by which it is taught. 

As anatomy and physiology, with chemistry, are the studies prepara- 
tory to medicine, one might expect that they should be made funda- 
mental to that of medicine ; that, starting from the knowledge of the 
healthy body, as taught by them, the transition should be easy and 
intelligible to disease — first, in its lowest degrees and simplest form ; 
then to the more compound, pronounced, and more removed from, but 
still comparable with, the healthy standard. Instead of this, lecturers 
and w T riters plunge at once into the mazy thickets of inflammation and 
fever — subjects so complicated, so changed from anything taught by 
previous study, that anatomy and physiology afford little help : and no 
wonder that the student (like many observers and reasoners on the same 
topics) becomes confused and bewildered in the complexity of the sub- 
ject; or, if he do make out anything, it is something isolated, abstract, 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



431 



about fever or inflammation itself, without its natural relations to health 
and to other diseases. 

This plan of proceeding may be compared to a person beginning the 
study of mechanics with the steam engine; or to the student of chemistry 
commencing with organic matter. 

The general result is, that where any distinct notion of disease is 
acquired, it is one not at all founded on previous physiological know- 
ledge, but it is a new idea of disease as an absolute, separate thing — not 
a mere condition consisting of altered function and structure, but a 
being, the character and history of which are to be detailed like that of 
a plant or an animal. And when special diseases are treated of, the 
same individualizing process is pursued through all the jargon of the 
schools. Each has its nosology, classification, and definition ; its pre- 
disposing, exciting, and proximate causes ; its theory, ratio symptoma- 
tum: its diagnosis, prognosis, indications of cure, fulfilment of these, 
juvantia et Icedentia, and prophylaxis ! 

With all this formidable array to each disease, the practice of physic 
was an arduous study in the days of Cullen. What must it be now, 
when the diseases of Cullen's nosology have been almost doubled, and 
the facts relating to them have been more than doubled ? 

But let us follow the student, well crammed with his nosological list, 
their definitions, &c, to the bedside. Let us see how his knowledge, 
so meritoriously and laboriously obtained, will serve him in the hour of 
need. In a few cases of fully developed and well marked acute diseases, 
such as pleurisy, scarlet-fever, or rheumatism, he may get on pretty 
well ; but in the commoner description of cases, acute or chronic, in 
their early stages, in their endless variations from peculiarities of con- 
stitution or from complicating causes, he finds himself continually puz- 
zled : the phenomena do not correspond with any of his defined dis- 
eases ; they frequently change their character in a way that he cannot 
account for ; his prognosis is falsified ; his diagnosis fails; and his treat- 
ment, although not always unsuccessful, does not answer according to 
his expectations ; some patients recovering whom he expected to die ; 
others dying, or not improving, whom he expected to recover. 

Disappointed in the failure of his nosological learning, the young prac- 
titioner more and more mistrusts it, and falls into a routine of empirical 
practice. Without troubling his head about the name or nature of dis- 
eases, he thinks solely of their treatment ; and, begrudging the time that 
he has spent with books and lectures, he decries everything that is not 
practical. 

Still he is obliged to retain some notions of the theory of disease ; but 
they are general notions, and not fettered by definitions. He still studies 
symptoms : he seeks in the pulse and heat of skin indications of fever 
and inflammation ; he looks to the tongue and alvine evacuations for 
proofs of disorder of the digestive organs ; he judges by the complexion 
and muscular strength the state of the constitution. Instead of trouble- 
some scholastic definitions, he uses convenient, general terms, which 
may be taken in a pretty vague sense — such as irritation, congestion, 
constitutional weakness, cachexia, disordered digestive organs, scrofula, 
scorbutic habit, and the like; and his remedial measures are designated 



432 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



in the same convenient general terras — such as soothing, cooling, sup- 
porting, stimulating, alterative, purifying, &c. 

In short, he has, in practice, learned himself, in a loose way, at the 
expense of previous studies, and sometimes, it is to be feared, at the 
expense of some bad practice, what he ought to have been properly 
taught as the foundation of his studies — general pathology. Thus we 
are led to the presumption that general pathology is the proper basis for 
practical medicine ; and I venture to affirm, that a chief reason why the 
practice of medicine has been commonly so distasteful, and so difficult 
in its study, and so unsatisfactory when tested at the bedside, is, because 
its foundation, general pathology , has not been efficiently taught. 

We have just met with a practical illustration of the truth, that gene- 
ral pathology is a more efficient help at the bedside than such knowledge 
of diseases as is to be obtained only from nosological definitions and de- 
tails. Before I proceed to exemplify this truth, by matters of every day 
experience, let me first briefly point out why it is so. 

Without the connecting link of general pathology, practical medicine 
derives little or no aid from anatomy and physiology. Instead of being 
founded on them, it is studied and practised quite independent of a full 
knowledge of them, and is generally acquired in proportion as they are 
forgotten. This kind of practical medicine is much the same as that 
of old women and nurses; it consists chiefly of treating symptoms, or 
groups of symptoms (called diseases), by remedies that have been found 
useful in similar cases, without the trouble of inquiring about the causes 
of the symptoms, or the precise seat of the disease. Thus, if a person 
complains of headache and giddiness, leeches are applied, purgatives 
are given, because they have been found useful in similar cases. An 
intimate knowledge of the structure and functions of the contents of the 
head would give no further help in the use of these remedies; nor sug- 
gest others, if these be found to fail. If they do fail, the only resource 
is in experiment: first one thing is tried, then another, until much mis- 
chief may be done, or at last, perchance, the right remedy may be hit 
upon; and this may be the very opposite of those first used. Long ex- 
perience may make the symptom-treating practitioner more successful, 
if he be an observing man; because it will acquaint him with additional 
symptoms to be considered for the guidance of the treatment. But there 
are -few of this class of practitioners w r ho are carefully observing men, 
who do remember and profit by their experience: they more generally, 
like their sisters, the nurses, keep pretty close to their first notions ; and 
although age and the name of experience may screen their failures, alas 
for the young adventurer who sets sail on this tack! 

But the benefit of such experience is gained at the commencement by 
the student of pathology. He has learnt to trace symptoms to their 
causes. Having been taught, by anatomy, the peculiarities of the cir- 
culation in the head — and by physiology, confirmed by clinical observa- 
tion, that this circulation may be similarly impeded by opposite causes, 
inanition as well as fullness, he is prepared to find out, through other 
symptoms, which is the cause of the headache in the case before him; 
and he adapts his remedies accordingly. 

In fact, a true pathology, or sound principles of medicine, is the em- 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



433 



bodiment of the results of experience in disease, with a knowledge of 
structure and function in health. It is the only connecting link between 
the preparatory sciences and practical medicine. Without it, these are 
disjecta membra; with it, they form a connected body of science — young 
yet, it is true, and falling short of the objects of the art, but already 
available for much, and needing only the growth and continued support 
of its chief members, especially anatomy, physiology, and clinical ob- 
servation, to become the perfect and efficient director of practical medi- 
cine. 

The great proof of the practical utility of general pathology is, the 
aid which it gives in the study of clinical medicine, and the light which 
clinical medicine continually throws on it. The states w T hich the prac- 
titioner has to treat are often too indefinite or too mixed to correspond 
w r ith any of the definitions of special disease. They frequently consist 
of functional disorder, varying with time and circumstance, or changing 
its place, so as to present no fixed characters. But, compared by the 
pathologist with the standard of health, and analyzed from their com- 
plexity, their nature becomes intelligible, and their proper treatment 
obvious, so far as means are possessed to counteract or control that 
which is wrong. Let us take one out of many examples. The dis- 
ordered state of health, for treating which Mr. Abernethy gained such a 
reputation, is one of the commonest ailments we have to prescribe for: 
some call it, with Abernethy, " all stomach;" others, "liver;" others, 
"disordered constitution;" others, "indigestion;" but however differ- 
ently they may name it, few refuse to treat it, as Abernethy did, by 
regulated diet, blue pill, and mild saline aperients, repeatedly adminis- 
tered. Now the pathologist analyzes the symptoms of such a state, and 
in the white or yellowish furred tongue, morbid eructations, tender epi- 
gastrium, sometimes full right hypochondrium, with extended dullness 
on percussion, the discolored feces, the high-colored and turbid urine, he 
finds proof of congestion and disturbed secretion of the liver and upper 
part of the alimentary canal; and he recognizes in the remedies em- 
ployed, means which, by increasing the secretions, relieve the conges- 
tion ; and if these fail, he can suggest other measures which he knows 
to be efficacious in removing congestion, and restoring the natural secre- 
tions. Again, what confusion in diagnosis, as well as in practice, has 
arisen from comprehending, under the specific name hysteria, the most 
opposite and most varying conditions, merely because they are consorted 
with some nervous phenomena ; so that this word becomes almost synony- 
mous with female diseases. But, pathologically considered, the confusion 
in diagnosis, and, in some measure, the perplexity in regard to treatment, 
cease. In one group of such cases, the pathologist finds really such signs 
of disordered uterine function as would justify the name ; other symptoms, 
however varied, taking their origin from this disorder; and he thus dis- 
covers the necessity of directing the treatment to this cause. In another 
group, again, he finds the uterine function impaired ; but this only in 
common with other functions: and all this in consequence of a want of 
blood throughout the body, which want is denoted by the waxy com- 
plexion, the pallid lips and gums, the loose yet easily quickened pulse, 
the panting breath, the feeble limbs, &c. Here the restoration of the 
28 



434 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



blood is the obvious indication; and in proportion as this is effected, the 
symptoms of nervousness, debility, and loss of function, disappear. In 
a third group of cases, called hysterical, the pathologist discovers the 
opposite condition, that of sanguineous plethora, which, independently 
of any disorder of the uterus, causes trouble, sometimes in one part, 
sometimes in another, but especially in the nervous system, which, in 
most females, is peculiarly liable to disorder. Here, too, he is led to 
the most appropriate treatment. 

This is but one instance out of many that might be adduced to show 
the great practical utility of a good knowledge of pathology. In fact, 
the leading rules of practice, those which guide the most experienced 
men, (although many are not aware of it, and would not acknowledge 
it,) are founded on general views of diseased function and structure — • 
that is, general pathology. You will not find that practical men treat a 
disease merely according to its name, or according to the nature of the 
local mischief. Inflammation is not always to be combatted by blood- 
letting, nor hemorrhage by styptics. The condition of the system — 
that is, of the functions, is to be taken into account; and the variations 
of this condition, the states of sthenia and asthenia, tone and debility, 
excitement and depression, plethora and anaemia, are the very subjects 
which general pathology explains and shows how to treat. 

I say, practitioners do act more on general ideas of disease than on 
their knowledge of particular diseases. They feel the pulse and the 
skin, to guide them in the use of blood-letting, whether they have found 
out the special disease or not. They examine the tongue, and inquire 
as to the state of the evacuations, to guide them in the use of purgatives, 
under whatever complaint the patient labors. They consider the com- 
plexion and bodily strength in connection with dietetic measures; and 
the chief treatment of convalescence depends on rules suggested by 
general pathological knowledge. 

There are other very important departments of medicine which are 
comprehended in general pathology, and with it have been too much 
neglected — I mean, the study of the causes of disease and their modes 
of operating on the living body, (etiology,) and the means by which 
they may be avoided or counteracted, including prophylaxis, or the pre- 
vention of disease ; and hygienics, preservation of health. Neither of 
these subjects can be satisfactorily comprehended without a sufficient 
knowledge of the elements and laws of disease. 

Is it not, therefore, most important that these general views, which 
are so practical and so extensive in their application, should be well 
founded and carefully studied? Is it right that the leading doctrines 
of disease, leading, not in theory but in practice, should, as hitherto, be 
left to be picked up irregularly, from casual retrospects of study or 
experience, when they may be learned as the very groundwork of prac- 
tical knowledge? 

What, then, is this general pathology, which we extol so much as the 
proper foundation of practical medicine? Let us first state what it is 
not. It is not a collection of hypotheses hung on solitary facts, and in- 
geniously devised to explain this or that symptom, or the modus operandi 
of this or that remedy. It is not anything floating on (I cannot say, 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



435 



founded on) conjectural notions in anatomy and physiology, such as the 
existence and circulation of a nervous fluid, the presiding influence of 
the ganglionic system, or the vital attractions and repulsions of the cir- 
culating fluids; notions which, however they may hereafter be substan- 
tiated, are at present too speculative to form a foundation for pathology. 
Nor is it a partial set of opinions, erected on one only of the many pedi- 
ments of fact on which the science of medicine should stand. Healthy 
anatomy, physiology, physics, chemistry, the study of clinical medicine, 
that of materia medica, morbid anatomy — neither of these alone can 
furnish a foundation for pathology — that foundation must be formed by 
all — the facts which all supply constitute the material of which it is 
built, and the general facts or laws of all must be brought to bear on 
the arrangement of these materials in the construction of a system of 
pathology. 

Some advancement in these contributory departments is necessary 
before the work can be begun, and it is because they have advanced, 
that the opportunity is afforded. Why should the science of medicine 
remain in a state of powerless infancy, when its members are progressively 
acquiring strength and maturity? Why should the art of medicine still 
be groping about in blind empiricism, and an unintelligible confusion 
of facts, when science even now can afford it the beginnings of light 
and of order? 

I have just said that the contributory sciences are sufficiently advanced 
to be generally applicable to practical medicine. The proofs of this in 
detail, will, I trust, appear in the progress of the course ; but I will ad- 
duce here a few examples of a prominent kind. Disease, in so far as it 
is the result of mechanical change, or in part made up of mechanical 
elements, may be properly treated by mechanical means. It was the 
knowledge of this fact which led Dr. Arnott to invent that admirable 
contrivance, the w T ater-bed, by which disease is often prevented and re- 
moved ; and he has lately made another application of physical science; 
in modes of applying pressure to parts with such equality as to control 
to any degree the circulation of the blood through them, and thus to re- 
lieve pain, remove congestion, subdue inflammation, heal ulcers, disperse 
swellings, and arrest the growth, if not to effect the removal, of tumors 
and other morbid productions. Disease, so far as it is physical in its 
nature and in its effects, is to be investigated by physical means. Hence 
the advantage of acoustic science in assisting us in diagnosis of internal 
disease, and of optical science in enabling us to witness the minutise of 
its operations and its products. I need scarcely add, that the treatment 
of disease is in some instances founded on, and in most cases guided by, 
knowledge thus obtained. 

As an example of improvements in anatomy and physiology bearing 
on practical medicine, I may mention the late researches on the nervous 
system, and especially those of Dr. Hall. By these, much that before 
was unintelligible in diseases of the nervous system has been satisfac- 
torily explained and their diagnosis and treatment have received propor- 
tionate aid. Considerable light has been thrown on diseases of the liver 
and of the heart, by recent anatomical and physiological investigations 
of these organs. 



436 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



The aids afforded by chemistry to the materia medica have been long 
acknowledged, and continue to increase ; but chemistry is growing in 
importance in its applications to every department of practical medicine. 
It is now directly useful in the diagnosis and treatment of diseases of 
the urinary organs. It furnishes a key to the most important rules of 
diet, in health as well as in disease, and bids fair to supply much that 
is wanting in explanation of the origin of many maladies, and the most 
direct mode of preventing them. It is through the aid of organic che- 
mistry, now far advanced — advanced, too, mainly by the labors and genius 
of an illustrious chemist, who this day honors us with his presence (Pro- 
fessor Liebig) — that we may hope that experimental physiologists and 
clinical observers will be enabled to solve some of the dark problems of 
the operation of medicines; a subject replete with practical importance, 
yet one that still lies chiefly in the region of conjecture. 

It will not be disputed that clinical observation has lately done much 
for the advancement of the science of medicine; and this, not only be- 
cause it is the test by which the contributions of other branches are tried, 
but also because in itself it is carried on with the minuteness and pre- 
cision which are essential to science. This precision must apply, not 
only to the modes of calculating facts, but also and most particularly to 
the correct determination and classification of these facts. The accuracy 
of counting is a mere facility in common arithmetic. The accuracy of 
observing and arranging the facts to be counted is the higher and rarer 
quality. Both are required in the prosecution of clinical research. 

The whole department of practical medicine teems with examples of 
the benefits which it has derived from morbid anatomy. What should 
we know of the nature, products, and tendencies of inflammations, and 
other diseases which alter the structures, but for the scalpel revealing 
them to our very sight and touch ? The minuteness with which it (mor- 
bid anatomy) has been pursued in connection with clinical observation, 
in regard to diseases of the lungs, heart, liver, kidneys, and alimentary 
canal, deserves especially to be mentioned as the great source of our 
improved theory and practice in these complaints. 

It is not a general or superficial knowledge of any of these funda- 
mental sciences that will avail to make them profitable to medicine. It is 
wmere their facts and laws have been carefully studied, in relation to the 
living body, that the advantage has become practical ; and this study has 
in many instances developed new phenomena, which reflect light also on 
the contributory science. The application of hearing to the distinction 
of diseases has given rise to a more intimate knowledge of acoustic 
science. Some of the most interesting facts and laws of organic che- 
mistry have resulted from researches instituted with reference to the 
investigation of disease ; as, for example, those of Prout, Wohler, and 
Liebig. In regard to anatomy and physiology, the instances are abun- 
dant. For example, the researches of Charles Bell, Foville, and M. 
Hall, on the nervous system, and those of Astley Cooper on the testicle 
and mamma, were conducted with express reference to diseases of these 
organs, and were often suggested by the knowledge previously possessed 
of these diseases. In this respect they followed John Hunter, who 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



437 



throughout his anatomical labors had an eye to pathology, and by observ- 
ing disease, was continually guided to objects for these labors. 

So we shall find, as we proceed to the details of pathology, that sub- 
jects which require further research are continually presented to us in a 
practicable form ; and I shall take occasion to point out these as they occur, 
in the hope that some among you may be induced to cultivate ground 
which is rich in promise of important practical results. 

Do not suppose, because I insist strongly on general pathology being 
the proper basis of practical medicine, that this will lead us to neglect 
the superstructure, special pathology. Individual diseases will be the 
chief subjects of the course, occupying 100 out of 150 lectures; and I 
trust that their details will become much more comprehensible by the 
arrangement into which general pathology will enable us to distribute 
them. It is because I feel the vast importance and extent of our know- 
ledge of individual disease, that I would endeavor to introduce you to 
it from the most advantageous and commanding position ; and that po- 
sition is afforded by a previous acquaintance with the general features 
of disease. In fact, individual diseases are like the leaves and boughs 
of the tree, of which general pathology constitutes the trunk and great 
branches — all preserving an identity and connection, yet each portion 
having peculiarities of character which require separate study. Or me- 
dicine may be compared to a great edifice, the foundation and chief en- 
trances of which represent pathology, which generally give the proper 
approach to the separate rooms, special diseases. To some of these, in 
the imperfect state of the structure, there may be access only by the dark 
back ways of blind experience, which then must not be neglected; but 
this is no reason for continuing to make these dark back ways the only 
entrance. 

Throughout our examination of the details of disease, we shall find 
the principles of general pathology continually exemplified ; and through 
these principles the mind can master the details to an extent wholly 
unattainable by those who pursue them as unconnected matters of fact. 
Those who begin the study of practical medicine by attempting to learn 
the details of diseases, are like those who would endeavor to master all 
the facts of chemistry without any knowledge of the general facts or laws 
of chemical action, affinity, and definite proportions ; yet even in practical 
chemistry, or chemistry applied to the arts and manufactures, the most 
extensive and important services have been obtained from these very 
principles, applied to the details. 

But in treating of individual diseases, although we shall find our pre- 
vious pathological principles of great use in explaining and simplifying 
the details, we are not to be tied to them whensoever experience varies 
from those principles, or goes beyond them ; then, experience must be 
carefully followed. There is no subject in which this simple statement 
of fact is more frequently necessary than in regard to the modus operandi 
of medicines. It is quite true, that many curious speculations have been 
offered on this subject. In fact, it seems to be quite the hobby, or the 
Pegasus, of a very speculative class of men who call themselves practical. 
These can tell you to a nicety how mercury cures syphilis; how opium 
causes sleep ; on what precise parts of the intestinal tube each variety 



438 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



of purgative acts, &c. But, as in most of such hypotheses, there is much 
more of fancy than of fact; and as the fancy, if erroneous, may be mis- 
chievous in a strictly practical matter, I shall be excused if I prefer giv- 
ing you the naked matters of fact. 

The purpose of lectures on the practice of medicine is not merely to 
convey knowledge of disease and its treatment, but also to direct the 
mind in the ways of using this knowledge, and of acquiring more. Books 
will supply details which cannot be given in the lectures; but the more 
important additional source of information is clinical instruction. This 
is an essential part of the teaching of practical medicine. It is its de- 
monstrative part, and is essential, not only because, like other witnessed 
phenomena, it appeals to the senses, but also because it is necessary to 
practise those senses in the examination of the signs of disease, and to 
exercise the reasoning pow T ers in the interpretation of those signs, and in 
the further application of previously acquired knowledge. As general 
pathology is the connecting link between the preparatory studies and 
practical medicine, so clinical instruction is the step between the know- 
ledge of medicine and the personal application of that knowledge in 
actual practice. I need not say that each of these is most necessary to 
the formation of a good practitioner: but there are especial reasons why 
clinical study, connected with the practice of medicine, is more indis- 
pensable now than it ever was. In former days, medicine was little more 
than a matter of routine; and the examination of a patient was summed 
up in feeling the pulse, looking at the tongue, and asking a few ques- 
tions as to the feelings and functions, and this was often done for the 
sake more of form than of information ; for the pills and draughts were 
much the same in most cases. This was little better than quackery, and 
required no great preparatory study. That it sometimes succeeded to 
win the favor of the public is not surprising, seeing that quackery often 
had a similar or greater success. Then the ignorant practitioner could 
disguise his emptiness by a cloak of mystery, and a solemnity of man- 
ner, and could command confidence by dropping a hint about his expe- 
rience, tact, and intuitive perception of disease. But, ignorant as people 
still are in medical matters, they are not so dull as to be deceived by 
these means. They have a smattering of physiology and the use of re- 
medies, and they are become troublesomely inquisitive ; and if they are 
taken in, it is by the clever quack, who is ready w 7 ith his theories and 
persuasive proportion of cures, and not by the unsatisfactory regular, who 
examines but little, and cannot explain his views or his practice. In 
short, the public look for what they have a right to expect, thoroughly 
educated practitioners, who prove their qualifications by their careful me- 
thod of investigating disease, the clearness with which they give their 
opinions, and the general correctness of those opinions. 

This, then, is another reason for thoroughly availing yourselves of 
practical instruction, especially in the clinical department. The great 
importance of this department has occasioned the adoption of extended 
measures for teaching it. It trust that you will prove, by the assiduity 
and success of your practical studies, that the college has not adopted 
these means in vain; but that, as in the preparatory branches, so in the 
finishing of your medical education, you will obtain that high standard 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



439 



of qualification that must insure the confidence and esteem of those 
among whom you may exercise your calling. 

Gentlemen, we have great pleasure in meeting you again for the ses- 
sion — those who have favored us before, as old friends; new-comers we 
welcome to the work, which, although arduous, is not one of drudgery. 
I almost envy the pleasure, in young and ardent minds, of rising step by 
step in knowledge, and delighting in the wonders and beauties of the 
enlarging view. I admit that the ascent is arduous — that it requires 
hard labor, and no little self-denial. But is there no compensation in 
the delight of acquiring knowledge and intellectual power? No gratifi- 
cation in learning and contemplating the intricate beauties of the most 
perfect part of the creation? Is there no moral and religious good to 
our own minds in tracing out and unveiling its frailties, weakness, decay, 
and death? No satisfaction in learning of means which a gracious 
Providence supplies for preventing and removing the ills which flesh is 
heir to ; for relief of pain, suffering and weakness, and restoration of health 
and strength? And if from present studies you carry your anticipations 
onwards to their final object in practice — under Heaven, yourselves to 
ease suffering humanity, and to invigorate and prolong life — is the pur- 
suit less noble, or less worthy of your highest thought? Need I say 
more for the intellectual and moral greatness of our art ? 

Is a study noble in proportion to the breadth and depth, and diversity 
of the knowledge on which it is founded? Then, think of medicine; 
how she levies her contributions from every branch of knowledge. The 
human body exhibits a machinery so perfect, that the most skillful me- 
chanical philosopher may take lessons from studying it. It contains a 
laboratory so diversified, and chemical processes so subtle, that therein 
the ability of the most expert chemist is far surpassed. But the know- 
ledge of the student of medicine must go beyond that of the mechanical 
and chemical philosopher. He must study those vital properties of which 
they can tell him nothing. He must become acquainted with the attri- 
butes of life operating in matter. In animal generation, nutrition, growth, 
secretion, motion, and sensation; in the variations of these processes, 
in their decay, and in their cessation, which is death, he has a compli- 
cated study, peculiarly his own, in addition to those of a more ele- 
mentary nature. He has, besides, to contemplate the body under disease, 
and to bring to his aid the three kingdoms of nature, and almost every 
art and every science, for agents and means to counteract and control 
that which disturbs its well-being. But is the body the only object of 
his care ? No. Mind and matter are too closely combined to be studied 
or treated apart. To medicine alone it belongs to contemplate and to 
treat the entire man — physical, moral, and intellectual. What can 
I say more of the intellectual greatness of our art ? 

Neither shall I strain your thoughts far to remind you of its moral 
worth. See its effect on masses of mankind, displayed in the progress 
of the happy discovery of Jenner! See how even barbarous people and 
idolaters, Musselmen, Hindoos, and Chinese, respect our nation only for 
the medical aid which it can supply. So that it has happened that 
medicine has become the handmaid of religion — a bond between coun- 
tries, a peace-maker between nations. 



440 



ON THE NEED OF PRINCIPLES IN MEDICINE. 



But let us not vaunt ourselves. Listen to one who speaks of our art 
— and that one the eloquent ambassador from the United States, the 
Honorable Edward Everett. I quote from the Times of the day before 
yesterday: — "For what was that which constituted the chief pride and 
glory of the British nation? They had heard of the intercepted letter 
from one Chinese chieftain to another; and what was the characteristic 
which had excited the admiration of the mandarin of a great and im- 
portant empire, reeling at the time under the blows of the British govern- 
ment? Was it the steam-vessels of war reaching coasts in defiance of 
the desolating simoom? Was it their arms — their artillery — their skill of 
engineering, which civilized nations now brought to the strategy of war? 
Was it this, or any of these, which had struck with wonder, and awe, 
and admiration, the barbarians of China? No! It was the humanity of 
British physicians and surgeons — their management of hospitals, and the 
generous kindness which was extended to the sick and wounded, even 
of a hostile nation — which moved them with astonishment, and excited 
their sympathy and regard. These w T ere some of the arts of peace which 
extorted the admiration of an enemy, and which other states would do 
well to imitate." 

But if you would see the moral influence of medicine depicted in its 
liveliest hues, I would ask you to contemplate a domestic scene — a family 
whose hearts are wrung with a dreadful anxiety for one vibrating between 
life and death. What a ministering angel does the physician seem! 
How they watch his every look! With what breathless earnestness do 
they hang on his words! and those words, how they wing themselves to 
the souls of the hearers for sorrow or for joy! Yet such scenes are 
passing daily and hourly in every class of society — in the mansion and 
in the cottage: they open the hearts of all; for the moral influence of 
medicine is bound up with the treasures of life and health, and with all 
those endearing ties that make these treasures doubly precious. Nay, 
how often, w T ith the hopes, or fears, of a blessed or an awful eternity! 

Do not think me too enthusiastic, nor overrating the profession you 
have chosen. Morally and intellectually I cannot overrate it: and now, 
at the commencement of a new epoch of your studies, when toil and 
exertion are required, I would cheer and encourage you, by reminding 
and convincing you of the intrinsic gratification which these studies may 
afford, and of the nobleness of the objects for which they prepare you. 

It is the fashion to decry our profession — to call it a poor profession, 
a degraded profession. If it be poor and degraded, is that the fault of 
the calling, or of those who practise it; or rather of those who should 
have governed and protected it? Is the art of healing in itself less noble, 
because its practitioners, unsupported by the arm of civil power, and too 
often unsustained by a consciousness of their own dignity, have not raised 
it to the place in society which it ought to hold ? Poor it may be, slighted 
it may be, but degraded it cannot, shall not be, so long as its foundation 
is science, and its end the good of mankind. 



THE END. 



